22814979 Visualization

A 26 Age - year Age - old Age woman Sex was seen Clinical_event in the emergency Nonbiological_location department Nonbiological_location ( ED Nonbiological_location ) for chest Biological_structure pain Sign_symptom and hypertension Sign_symptom .
She was found to have a urinary Biological_structure tract Biological_structure infection Disease_disorder and was sent home with an antibiotic Medication and thiazide Medication diuretic Medication .
Two Date days Date later Date , she returned with epigastric Biological_structure pain Sign_symptom , nausea Sign_symptom , emesis Sign_symptom and myalgias Sign_symptom .
The patient had no History significant History medical History history History and denied cardio Sign_symptom - respiratory Sign_symptom symptoms Sign_symptom ; however, she complained of a low Sign_symptom exercise Sign_symptom tolerance Sign_symptom for the last Duration year Duration .
There was no Family_history family Family_history history Family_history of Family_history cardiac Family_history or Family_history pulmonary Family_history disease Family_history or Family_history of Family_history sudden Family_history cardiac Family_history death Family_history .
She was born Personal_background in Personal_background the Personal_background USA Personal_background and had neither History travelled History recently History nor History had History any History sick History contacts History .
On examination, she was hypertensive Sign_symptom ( 170/105 Lab_value   mm Lab_value   Hg Lab_value ), tachycardic Sign_symptom ( 125 Lab_value   bpm Lab_value ), had dry Sign_symptom mucous Biological_structure membranes Biological_structure and appeared Diagnostic_procedure ill Lab_value looking.
She was found to have an elevated Lab_value serum Diagnostic_procedure creatinine Diagnostic_procedure of 160 Lab_value   μmol/l Lab_value (normal 60–110 μmol/l).
After receiving 1.5 Volume  l of intravenous Administration fluids Medication for presumed volume Disease_disorder depletion Disease_disorder and prerenal Detailed_description azotaemia Sign_symptom she became short Sign_symptom of Sign_symptom breath Sign_symptom .
Crackles Sign_symptom were noted on auscultation Diagnostic_procedure of her chest Biological_structure and a portable Detailed_description chest Biological_structure film Diagnostic_procedure demonstrated hazy Texture infiltrates Sign_symptom that likely represented pulmonary Disease_disorder oedema Disease_disorder .
She then developed hypotension Sign_symptom with systolic Diagnostic_procedure pressures Diagnostic_procedure in the 90s Lab_value .
Non Detailed_description - invasive Detailed_description positive Detailed_description pressure Detailed_description ventilation Therapeutic_procedure was initiated.
An ECG Diagnostic_procedure demonstrated sinus Sign_symptom tachycardia Sign_symptom with a rate Diagnostic_procedure of 130 Lab_value   bpm Lab_value and minimal Severity ST Sign_symptom depression Sign_symptom on the precordial Diagnostic_procedure leads Diagnostic_procedure .
In consultation Clinical_event with a cardiologist Subject , the patient received 40 Dosage   mg Dosage of intravenous Administration furosemide Medication .
An echocardiogram Diagnostic_procedure demonstrated global Detailed_description hypokinesis Sign_symptom with a left Diagnostic_procedure - ventricular Diagnostic_procedure ejection Diagnostic_procedure fraction Diagnostic_procedure <10% Lab_value (see figure 1).
The patient was transferred Clinical_event to the intensive Nonbiological_location care Nonbiological_location unit Nonbiological_location where she became more anxious Sign_symptom and tachycardic Sign_symptom to 170 Lab_value   bpm Lab_value .
She was intubated Therapeutic_procedure and sedated Medication .
Despite the placement of a Foley Detailed_description catheter Therapeutic_procedure and administration of intravenous Administration loop Administration diuretics Medication , she remained anuric Sign_symptom for the first Duration 12 Duration   h Duration of hospitalisation Clinical_event .
She developed signs of acute Detailed_description kidney Disease_disorder injury Disease_disorder with a creatinine Diagnostic_procedure that increased Lab_value to 350 Lab_value   μmol/l Lab_value within Time the Time first Time 24 Time   h Time of hospitalisation Clinical_event .
She received norepinephrine Medication and milrinone Medication to improve Lab_value cardiac Diagnostic_procedure output Diagnostic_procedure .
On the second Date day Date of hospitalisation Clinical_event , she was evaluated Diagnostic_procedure by a cardiologist Subject and cardiothoracic Subject surgeon Subject for emergent Detailed_description circulatory Therapeutic_procedure support Therapeutic_procedure as she had developed signs of poor Sign_symptom tissue Sign_symptom perfusion Sign_symptom with a lactic Sign_symptom acidosis Sign_symptom ( 8.4 Lab_value   mmol/l Lab_value ; normal <2.2 mmol/l) and transaminitis Sign_symptom with aspartate Diagnostic_procedure aminotransferase/alanine Diagnostic_procedure transaminase Diagnostic_procedure >150 Lab_value   IU/l Lab_value (normal <40 U/l).
She was taken Clinical_event to the cardiac Nonbiological_location catheterisation Nonbiological_location laboratory Nonbiological_location for emergent Detailed_description right Detailed_description heart Therapeutic_procedure catheterisation Therapeutic_procedure and biopsy Diagnostic_procedure to exclude acute Detailed_description myocarditis Disease_disorder .
Over Duration the Duration next Duration few Duration days Duration , she was gently Detailed_description fluid Therapeutic_procedure resuscitated Therapeutic_procedure ( guided Detailed_description by Detailed_description bioreactance Detailed_description non Detailed_description - invasive Detailed_description cardiac Detailed_description output Detailed_description ), the pressors Medication were gradually weaned off and she became non Sign_symptom - oliguric Sign_symptom .
She slowly Lab_value regained Lab_value renal Diagnostic_procedure function Diagnostic_procedure and organ Diagnostic_procedure perfusion Diagnostic_procedure improved Lab_value with resolution of the lactic Sign_symptom acidosis Sign_symptom and a decrease Lab_value in liver Diagnostic_procedure transaminases Diagnostic_procedure .
On hospital day Date 5 Date she was transferred Clinical_event to the medical Nonbiological_location ward Nonbiological_location and was eventually discharged Clinical_event home Nonbiological_location on non Detailed_description - selective Detailed_description β Medication blockade Medication , an ACE Medication inhibitor Medication and nitrate Medication with planned follow Clinical_event - up Clinical_event at the heart Nonbiological_location - failure Nonbiological_location clinic Nonbiological_location .
The patient returned Clinical_event to the ED Nonbiological_location 4 Date   days Date later Date with an elevated Lab_value blood Diagnostic_procedure pressure Diagnostic_procedure , nausea Sign_symptom and abdominal Biological_structure pain Sign_symptom .
A contrast Diagnostic_procedure scan Diagnostic_procedure of her abdomen Biological_structure revealed pancreatitis Disease_disorder and an adrenal Biological_structure mass Sign_symptom .
During her treatment Therapeutic_procedure for pancreatitis Disease_disorder she began to have paroxysms Sign_symptom of headaches Sign_symptom , nausea Sign_symptom , emesis Sign_symptom and abdominal Biological_structure pain Sign_symptom with corresponding hypertension Sign_symptom to the 220s Lab_value systolic Detailed_description and tachycardia Sign_symptom to 120s Lab_value with a baseline systolic Diagnostic_procedure pressure Diagnostic_procedure of 90–110  mm Lab_value   Hg Lab_value (see figure 2).
Her urinary Detailed_description and plasma Detailed_description catecholamines Diagnostic_procedure were elevated Lab_value and confirmed on repeat testing.
She was given aggressive Detailed_description fluid Therapeutic_procedure rehydration Therapeutic_procedure and α Medication and Medication β Medication blockade Medication for a planned adrenalectomy Therapeutic_procedure .
Prior to surgery Coreference her left Diagnostic_procedure - ventricular Diagnostic_procedure ejection Diagnostic_procedure fraction Diagnostic_procedure had improved Lab_value to 55% Lab_value on medical Therapeutic_procedure management Therapeutic_procedure (see figure 1).
Pathology Diagnostic_procedure of her adrenal Biological_structure gland Biological_structure was consistent with a non Detailed_description - malignant Detailed_description pheochromocytoma Disease_disorder (see figure 3).