Journal of Acute Disease

89-95

Authors: Rushikesh S. Haridas, Sheetal Shelke, Girish Patrike, Deepak Patil, Sainath Dhumal

Objective: To evaluate morphine's risk-benefit profile in the treatment of acute heart failure. Method: Different electronic databases, including PubMed, MEDLINE, Cochrane Library, and Google Scholar, as well as clinicaltrails.gov, were searched for articles published between 2012 and 2022. The risk of bias in the present study was evaluated by employing randomized controlled trials (RCTs) checklist that assesses the effectiveness of new interventions through random assignment of participants to different treatment groups. The two-part tool was used to address the five specific domains such as selection bias, performance bias, detection bias, attrition bias, and selective reporting bias. Evaluation of the quality of diagnostic accuracy studies was conducted using the RevMan software (version 5.4), a quality assessment tool. Results: A total of 13 studies were included in the present review, in which there were 5 retrospective studies, 3 randomized-control studies, 2 prospective studies, 1 multicenter pharmacodynamics study, 1 multicenter cardiac magnetic resonance imaging study, and 1 open-label, cross-over study. The mortality of acute heart failure patients treated with morphine was higher compared to those without morphine. Conclusions: Acute heart failure patients who do not receive morphine have a lower mortality rate compared to those who receive morphine. Considering the adverse effects, including mortality associated with morphine, there is a pressing need for further research to explore alternative and effective treatment options in acute heart failure.

102-106

Authors: Sanjana Agrawal, Abhiruchi Galhotra, Saurabh Kumar Sahu, Senthilkumar Ramasamy

Objective: To investigate the impact of COVID-19 on the mortality trends and patterns in a tertiary teaching hospital in Raipur, Chhattisgarh, India. Methods: A hospital-based retrospective study was conducted to analyze the case reports of all deaths from January 2016 to December 2021 in a tertiary teaching hospital in Raipur, Chhattisgarh, India. The socio-demographic profile and the pattern of causes of death were recorded. The deaths were classified according to the 10th revision of the International Classification of Diseases. Results: A total of 6128 deaths were registered from 2016 to 2021 and the maximum death number was observed in 2021 (38.2%) followed by 2020 (32.5%) when the country was hit by the COVID-19 pandemic. The highest number of deaths was observed in the age group of 51 to 65 years i.e., 31.1% of the total deaths. In all five years, male deaths were more than female deaths, and more than 50% occurred within three days of hospitalization during the study period. Conclusions: Even though there is a rise in the death rate due to the sudden hit of COVID-19, the burden of both communicable and non-communicable diseases remains gradually increasing over the five years. There is a need for health awareness in the community about changing lifestyles and their harmful effects on health.

114-120

Authors: Sumbul Qamar, Mohd Ayub Ansari, J. N. Mohapatra, Sana Salim Khan

Objective: To determine the association of the three umbilical cord blood parameters: umbilical cord pH, base deficit, and lactate levels, with neonatal outcomes. Methods: This prospective observational study was conducted from April 2021 to September 2022 with 100 term and late preterm (>35 weeks) neonates whose umbilical cord blood pH was <7.10, Apgar score was <7 at 1 min, and required positive pressure ventilation. Umbilical cord blood was assessed for pH, base deficit, and blood lactate levels. The neonatal outcomes of neonatal intensive care unit admission, Apgar score at 1 min, and Apgar score at 5 min were assessed. Results: The mean of umbilical cord blood pH was 7.04±0.07, mean base deficit was (–9.3±3.9) mmol/L, and mean lactate levels were (6.51±2.29) mmol/L. Neonatal intensive care unit (NICU) admission was needed in 78 (78%) neonates. The mean NICU stay length was (2.4±2.2) days ranging from 0 to 12 days with a median of 2 days. Univariate analysis showed no significant difference in cord blood pH (P=0.736) and base deficit (P=0.393) between neonates without NICU admission and neonates who required NICU admission, but lactate level was significantly higher in neonates who required NICU admission (P<0.001). There was no significant difference in cord blood pH (P=0.400) and base deficit (P>0.999) between neonates with Apgar scores 4-7 at 1 min and neonates with Apgar scores <4, but lactate level was significantly higher in neonates with Apgar scores <4 at 1 min (P<0.001). Conclusions: Umbilical cord blood pH, base deficit, and lactate levels are useful novel markers showing a significant correlation with neonatal intensive care unit admission and adverse neonatal morbidities among hypoxic newborns. Overall, lactate was a better predictor of adverse neonatal outcomes as compared to umbilical cord blood pH and base deficit.

129-130

Authors: Wai Yan Lam, Sunny Chi Lik Au

NA

45-50

Authors: Maryam Ziaei, Hojjat Rastegari Najafabadi, Mahjoubeh Keykha, Mehdi Galavi, Ali Abdolrazaghnejad, Alireza Bahmani

Objective: To investigate the therapeutic effects of supplemental oxygen on patients with myocardial infarction. Methods: This study was a randomized, double-blind clinical trial. The study population included all patients who were admitted to the emergency room of Ali-ibn-Abitaleb and Khatam-al-Anbia hospitals in Zahedan within six hours of the onset of classic symptoms of myocardial infarction. The patients (n=47) were divided into two groups: the case group (with oxygen therapy) and the control group (without oxygen therapy). The initial follow-up was evaluated after one month and the second follow-up was evaluated after three months in the target population in terms of mortality caused by acute myocardial infarction, mortality caused by any other cause, and re-hospitalization caused by acute myocardial infarction. Results: Out of the 47 patients, 27 were male (57.4%). The average age of the patients was (60.9±8.1) years. One month after admission, 2 patients (8.7%) in the case group and 2 patients (8.3%) in the control group died due to acute myocardial infarction. A total of 7 patients (14.9%) died three months after admission. There was no significant difference between the control and case groups in terms of mortality caused by acute ischemia within one and three months. After one month, 2 patients (8.7%) in the case group and 1 patient (4.2%) in the control group died of other causes. After three months, 4 patients (8.5%) in total died for other causes. There was no significant difference between the control and case groups in terms of mortality due to other causes within one and three months. One month after admission, 5 patients (21.7%) of the case group and 4 patients (16.7%) of the control group were re-hospitalized due to acute myocardial ischemia. During the next three months, 3 patients (13.0%) of the case group and 5 patients (20.8%) of the control group were re-hospitalized. There was no significant difference between the control and case groups regarding the rate of re-hospitalization caused by acute myocardial infarction within one and three months after admission. Conclusions: There is no significant relationship between oxygen therapy and death by acute myocardial ischemia, or any other causes. The relationship between oxygen therapy and the rate of re-hospitalization caused by acute myocardial ischemia is not found within one and three months after admission. The results show that oxygen therapy does not affect patients with acute myocardial ischemia within three months after admission.

57-60

Authors: Pankaj Jain, Manoj Sharma, Manoj Seval, Pramod Meena

Objective: To study epidemiology, clinical manifestations, and laboratory parameters of scrub typhus in Hadoti region of Rajasthan, India. Methods: A cross-sectional study was conducted on 50 patients with scrub typhus between August 2022 and November 2022. Scrub typhus was diagnosed by ELISA IgM scrub typhus antibody. The data about demography, vital parameters, and lab investigations were collected and analyzed. Results: Ninety-two percent of the patients were from a rural background (92%), 86% were farmers and the majority were females. Most patients were 40-60 years old. The major complaints were fever (100%), myalgia (100%), headache (82%), and body swelling (80%). Major complications were pneumonia (68%), multiple organ dysfunction syndrome (62%), hepatitis (44%), and acute kidney injury (42%). Triglyceride levels were >200 mg/dL in 80% of patients, albumin <3.5 g/dL in 98% and eschar mark was present in 24% of patients. Conclusions: Scrub typhus is a serious acute febrile illness that can lead to multi-organ dysfunction and is associated with significant mortality. Increasing awareness regarding disease in endemic regions, early screening of patients, and treatment as early as possible could help prevent the patient from severe life-threatening complications.

67-72

Authors: Mudita Sharma, Digpal Singh Chundawat, Rohit Richhariya, Sunil Kumar Tailor, Shatrughan Pareek

Objective: To assess perceived stress and coping capacity of frontline health workers from AIIMS during COVID-19 pandemic. Methods: This cross-sectional study conducted from May to July 2021 enrolled 694 participants. An online questionnaire based on Google Forms was developed to collect the data. Participants were assessed using the validated Perceived Stress Scale and the Coping Resources Inventory Scale. Results: The age of participants were 27 (23-52) years old. The majority of respondents (73.5%) felt moderately stressed. Of the 694 participants, 83.0% of the 576 participants had average stress management skills. Sex, marital status, and profession were significantly associated with perceived stress. In addition, marital status and profession were significantly associated with coping capacity. Conclusions: The majority of participants have moderate stress levels and average coping skills. Frontline healthcare workers have to maintain mental and physical health. Achieving this requires early screening and stress management for healthcare workers.

80-82

Authors: Eduardo Esteban-Zubero, Cristina García-Muro, Moisés Alejandro Alatorre-Jiménez, Carlos Arturo López-García, Alejandro Marín-Medina

Rationale: Thrombosis of the internal jugular vein is an infrequent and underdiagnosed pathology due to the absence of symptoms. If present, the symptoms are frequently manifested as a sensation of pain and cervical tension. Its etiology is variable, including trauma, central catheterization, and hypercoagulable states, among others. Patient’s Concern: A 41-year-old female, previously healthy, was admitted to the emergency room for worsening pain in the left cervical area of 5 d. Previously, she was treated for suspected acute pharyngotonsillitis yet without improvement. Diagnosis: Physical examination revealed a 2 cm in length cervical mass of hard consistency that was painful on palpation and non-fluctuating. Ultrasound study showed thrombosis of the left internal jugular vein. A computed tomography scan revealed that the thrombosis occurred at the cervical portion of the left internal jugular vein as well as the left transverse sinus. Interventions: Hospital admission and treatment with low molecular weight heparin at a dose of 1.5 mg/kg every 24 h. Outcomes: The patient was discharged after 3 d of treatment with vitamin K antagonists. Lessons: Venous thrombosis at the level of the internal jugular vein is an infrequent entity. Clinical suspicion is necessary for the diagnosis given the possibility of absence of symptoms.

87-88

Authors: Majed Abdul Basit Momin, Rathore Rahul Dev Singh, Rubina Hassan

NA

1-9

Authors: Abdel-Hady El-Gilany, Hala Abou-ElWafa

Many underdeveloped countries still struggle with the public health issue of acute illnesses, especially with the emergence of injuries as a major category of acute diseases. Control of the acute disease is challenging particularly when it occurs as an outbreak, either in isolation or as part of a wider epidemic. This narrative review summarizes the definition, epidemiologic transition, pattern and modes of spread, classification, epidemiologic measures, community burden, prevention, control, and future challenges of acute disease. This review is to provide a reference for epidemiologists, clinicians, researchers, and policymakers.

18-22

Authors: Damla Anbarli Metin, Hamdi Metin, Seref Emre Atiş

Objective: To evaluate the effect of the modified systemic inflammation score (mSIS) on prognosis in patients diagnosed with COVID-19. Methods: In this retrospective cross-sectional study, 181 patients were selected and divided into two groups: patients with and without admission to the intensive care unit (ICU). An albumin level of ≥4.0 g/dL and lymphocyte-to-monocyte ratio (LMR) of ≥3.4 was scored 0, an albumin level of <4.0 g/dL or LMR of <3.4 was scored 1, and an albumin level of <4.0 g/dL and LMR of <3.4 was scored 2. Results: A total of 242 COVID-19 positive patients were initially included in this study. Of these patients, 61 were excluded and 181 patients remained. Among the 181 participants, 94 (51.9%) were female, and the median age was 61 (51, 75) years. The mSIS scale ranged from 0 to 2. After analysis, the median score was 0 (0, 0) in the non-ICU group and 2 (0, 2) in the ICU group (P<0.001). The median white blood cell, lymphocyte counts, and albumin levels were lower in the ICU group (P<0.001, P<0.001, and P<0.001, respectively). In logistic regression analysis lymphocytopenia (OR=5.158, 95% CI=1.249-21.304, P=0.023), hypoalbuminemia (OR=49.921, 95% CI=1.843-1 352.114, P=0.020), AST elevation (OR=3.939, 95% CI=1.017-15.261, P=0.047), and mSIS=2 (OR=5.853, 95% CI=1.338-25.604, P=0.019) were identified as independent predictors of ICU admission. Conclusion: The mSIS can be used as an independent parameter for establishing the intensive care needs of patients with COVID-19.

29-34

Authors: Hamed Delam, Ahmadreza Eidi, Zahra Keshtkaran, Omid Soufı, Behzad Rezaei, Mohammad-Rafi Bazrafshan

Objective: To investigate the trend of animal bites in southern Iran from 2015 to 2019. Methods: This is a cross-sectional study of patients with animal bites who were referred to the Center for Disease Control in the three cities of Larestan, Evaz, and Khonj in Fars province, southern Iran from 2015 to 2019. The trend of animal bites incidence was analyzed using the Cochran-Armitage trend test. Results: In total, from 2015 to 2019, 1 944 cases of animal bites were reported. A total of 79.8% of the cases were men. The overall average incidence of animal bites was 142.93 per 100 000 people. The incidence of animal bites was significantly increased (Ptrend<0.001). The highest incidence was in November (79.04 per 100 000 people) followed by January (76.1 per 100 000 people) and February (69.48 per 100 000 people); also, the lowest incidence was in August (47.42 per 100 000 people) and July (50.0 per 100 000 people). Conclusions: The incidence of animal bites has significantly increased. Given the importance of rabies, control and management of animal bites should be emphasized and considered.

39-42

Authors: Rishi Agarwal, Hardeva Ram Nehara, Babulal Meena, RP Agrawal

Rationale: Pituitary apoplexy (PA) is a rare endocrine emergency that requires prompt diagnosis and management. Dengue fever-induced-thrombocytopenia may rarely predispose to PA. Patient's Concern: A 58-year-old male patient having known pituitary macroadenoma presented to the emergency department with fever, a sudden onset severe headache, and altered sensorium. Diagnosis: Pituitary apoplexy caused by dengue fever-induced-thrombocytopenia. Interventions: Conservative management with fluids, mannitol, dexamethasone and symptomatic treatment. Outcomes: The patient responded well to the treatment and was discharged uneventfully. Lessons: Although dengue hemorrhagic fever is a rare cause of pituitary apoplexy, it should be considered if a patient presents with headache and altered sensorium, and prompt initiation of treatment is crucial to prevent fatality and neuro-ophthalmic deficits.

212-221

Authors: Adel Khalifa Sultan Hamad

Thrombotic complications appear to be a major predictor of death in COVID-19 patients, and multiple studies have shown that anticoagulants can help to improve the outcome. The Food and Drug Administration’s acceptance of non-vitamin K antagonist oral anticoagulants (NOACs) has sparked much excitement about their potential as a replacement for existing oral anticoagulants. NOACs target a single clotting factor, often activated factor X or thrombin, and involve the coagulation factor Xa inhibitors including apixaban, edoxaban, and rivaroxaban, and the thrombin inhibitor dabigatran. COVID-19 is an infectious disease that causes thrombotic events by inducing a pro-inflammatory and prothrombotic condition. This article provides a comprehensive overview of the mechanism behind enhanced thrombogenicity accompanying COVID-19, the clinical range of NOACs, and the role of NOACs in treatment of COVID-19 based on recent investigations and clinical trials.

228-235

Authors: Çiğdem Samanci Tekin, Selma İnfal Kesim

Objective: To uncover the impact of centralization of COVID-19 and perceived control of COVID-19 on society during the pandemic. Methods: We recruited a total of 1041 people in this cross-sectional study. The data were collected using a questionnaire booklet covering demographics, a COVID-19-related information form, the Centrality of Event Scale, and the Perception of Control of COVID-19 Scale. We utilized independent samples t-test, chi-square test, and one-way analysis of variance to analyze the data. Results: 1041 questionnaires were collected and no questionnaire were excluded from our study. Slightly more than half of the participants (51.2%) stated that social isolation impaired public mental health, while 30.1% reported adverse impacts of the pandemic on their sleep quality. Participants with changes to their sleep patterns were found to centralize COVID-19 more. Moreover, measures against COVID-19 and constant announcements of the daily number of cases in the media brought both positive and negative effects on people and further contributed to the participants’ centralization of COVID-19. Individuals with low centralization scores were concluded to perceive COVID-19 as a minor disease. Healthcare professionals without a relative diagnosed with COVID-19 and those satisfied with treatment opportunities had a higher perceived control of COVID-19, while those who were not interested in statistical data on COVID-19 and who had difficulty complying with the rules had a lower perceived control of COVID-19. Besides, poorer perceived control of COVID-19 was found to adversely affect sleep quality. Furthermore, healthcare professionals scored higher on the inevitability subscale of the Perception of Control of COVID-19 Scale. Finally, among the participants, most COVID-19 survivors thought COVID-19 to be an avoidable disease. Conclusion: In addition to its physical impacts, COVID-19 adversely impacts on mental health, and these effects are closely linked to a society’s centralization of COVID-19 and perceived control of COVID-19.

243-246

Authors: Mojtaba Yousefzadeh, Azadeh Asgarian, Roghayyeh Ahangari, Zahra Yazdi, Marzieh Savari, Monireh Mirzaie, Fatemeh Bagheri, Abolfazl Mohammadbeigi

Objective: To report the maternal death due to COVID-19. Methods: A total of 14 maternal deaths due to severe and critical COVID-19 who were referred to the obstetric department of Nekouie-Forghani-Hedayati Hospital, Qom, Iran from December 2019 to May 2022 were collected. The clinical manifestations and maternal and perinatal outcomes were analyzed. Results: Dexamethasone was used in 7 cases, while remdesivir was used in 5 cases. Acute respiratory distress syndrome, multiple organ failure, and sepsis were the main cause of mother death. The pregnancy in 8 cases were terminated by caesarean and only one neonatal death was reported from a mother at 13th week of gestational age, while all other fetus delivered were healthy and alive. Conclusions: COVID-19 in pregnancy is an emergency. Critical appraisal is needed to detect the other comorbidities and positive PCR test by throat swap should be performed as soon as possible.

251-253

Authors: Alireza Bahmani, Ali Abdolrazaghnejad

Rationale: Peptic ulcer disease and variceal bleeding are two of the most common causes of gastrointestinal (GI) bleeding. GI bleeding can present with symptoms of hemodynamic instability such as tachycardia and shock. Patient’s Concern: A 33-year-old man with confusion and hypotension (blood pressure: 70/40 mmHg and pulse rate: 140/min) was brought by emergency medical services from home to the emergency department without any companion. The patient was in undifferentiated shock. His hypotension was assessed with inferior vena cava (IVC) size and collapsibility, and rapid ultrasound in shock and hypotension (RUSH) protocol was used to investigate the cause of his shock. Following the RUSH protocol when scanning the IVC, parts of the stomach were seen in its vicinity and suspended heterogeneous particles were observed in the fluid. After seeing these particles, we suspected GI bleeding. Diagnosis: Endoscopy confirmed GI bleeding. Interventions: After placing an orogastric tube and suction, about 2 L of coffee-ground fluid with clots was removed. We started intravenous proton-pump inhibitors 80 mg bolus, followed by a continuous infusion of 8 mg/h. The patient received about 2 L of normal saline and 2 units of packed red blood cells to correct his hypotension. Outcomes: After being admitted to the GI ward and treated for three days, the patient was discharged from the hospital with a hemoglobin level of 11 g/dL and continued to have an outpatient follow-up at the clinic. Lessons: The use of gastric ultrasound in conjunction with the RUSH protocol can help to diagnose undifferentiated hypotensive shock. The components of the RUSH exam are the heart (H), IVC (I), Morrison’s/FAST abdominal views with the aorta (MA), and pulmonary and pipes scanning (P), and can be memorized with the mnemonic: HI-MAP. We would like to introduce a new mnemonic: Hi-MAPS, adding stomach (S) to the RUSH protocol in undifferentiated hypotension and shock to evaluate upper GI bleeding.

168-172

Authors: PK Rajeesh Mohammed, Saakshi Gulati, Shivangi Gupta

The ongoing COVID-19 pandemic due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has resulted in a significant public health care system crisis. This disease has resulted in devastating damage to human lives and significant disruption in economies. Use of “machine-learning” algorithms as tools of artificial intelligence may help identify a suspected or infected individual with an estimation of chances of survival. These algorithms make use of recorded observational data including medical histories, patient demographics as well as any related data on COVID-19.

181-187

Authors: Hesameddin Modir, Esmail Moshiri, Mehran Azami, Maryam Joshaghani Zad, Amir Almasi Hashiani

Objective: To compare the effect of ketamine, lidocaine, acetaminophen, and dexmedetomidine combined with morphine patient-controlled analgesia for opium addicts after tibial fracture surgery. Methods: This double-blind clinical trial included opium-addicted patients undergoing tibia fracture surgery. Patients were recruited and randomized to four different groups including the ketamine group, the lidocaine group, the acetaminophen group, and the dexmedetomidine group. The hemodynamic parameters such as heart rate (HR), mean arterial pressure, and arterial SaO2, alongside visual analog scale pain scores, sedation assessed by Ramsay score, nausea and vomiting, and opioid use were recorded and compared among the four groups. Results: This study included 140 patients, aged 37 (32, 41) years, with 92 males and 48 females, and each group had 35 patients. Dexmedetomidine-sedated subjects had the lowest blood pressure from 1 to 24 h after surgery, decreased HR at 12 and 24 h after surgery, and more satisfactory sedation (P<0.05). Notwithstanding no significant difference was noted in the pain scores, or nausea and vomiting among the groups (P>0.05). Conclusions: Dexmedetomidine has a better sedation effect compared to ketamine, lidocaine, and acetaminophen for pain control, but the final choice hinges on the patients’ physical condition and the anesthesiologist's preference. Clinical registration: It is registered in Iranian Registry Clinical Trial by code IRCT20141209020258N146.

194-198

Authors: Furkan Tontu, Sinan Asar, Beyza Oren Bilgin

Objective: To investigate the effect of the variability of Nas, Cls, Ks, lactate values and sodium effect (NaEffect), chloride effect (ClEffect), non-lactate strong ion difference (SIDnl) values calculated according to Stewart’s approach on predicting intensive care unit (ICU) mortality. Methods: The study was conducted on 1539 patients, retrospectively. Serum Na (Nas), serum Cl (Cls), serum K (Ks), serum Ca (Cas), serum Mg (Mgs), lactate, pH values and SIDnl, NaEffect, ClEffect, APACHE II (first, last), and SOFA (first, last) scores were recorded. Radiometer ABL 800 (Denmark) was used for blood gas analysis. The variability of each parameter was calculated. The effect of variability of each parameter on 30-day ICU mortality was analyzed. Results: The variability of lactate (P<0.001, OR=0.580, 95% CI=0.505-0.652), pH (P=0.001, OR=0.004, 95% CI=0.000-0.104), NaEffect (P<0.001, OR=0.550, 95% CI=0.378-0.592), Ks (P<0.001, OR=0.385, 95% CI=0.244-0.565) values were protective factors of ICU mortality and Cls value was a risk factor (P=0.004, OR=1.095, 95% CI=1.024-1.164). Variability of ClEffect, SIDnl values did not affect ICU mortality. Conclusions: The variability of electrolytes is important. Electrolyte, effects, and lactate variability can guide treatment and fluid applications in ICU.

202-205

Authors: Abdulkerim Gokoglu, Hasan Tahsin Gozdas, Selime Ozen, Sonay Gokoglu

Rationale: There are many cases of daily reported dog bite injuries around the world. However, craniofacial fractures owing to dog bites are quite rare. They are frequently seen in the pediatric age group. Here, we report the successful management of a pediatric patient with depression skull fracture due to a dog bite injury. Patient’s concerns: A 3-year-old boy was admitted to the emergency department with a complicated skull fracture due to a dog bite injury. In physical examination, the patient was neurologically intact. He had hemorrhagic scalp wounds. Cerebrospinal fluid was leaking on the right temporal and frontal sides. Diagnosis: Cranial computed tomography revealed pneumocephalus, brain edema, and compound fracture associated with right frontal concussion. Intervention: After decompressive craniectomy, duraplasty was performed by placing a galea graft. Depressed fractures were removed and subdural bleeding control was provided. Outcomes: Perioperative and postoperative periods were uneventful. Lessons: Emergency medicine physicians should control possible underlying fracture lines in pediatric head trauma caused by dog bites.

209-211

Authors: Eunizar Omar, Yasheen Krishna Persand

Rationale: As an uncommon manifestation of congestive heart failure, congestive hepatopathy requires an early diagnosis in order to render appropriate care. Misdiagnosis as intraabdominal sepsis may lead to erroneous initial intervention, such as fluid boluses, that can potentially tip an already sick patient with poor reserves over into an extreme state. Patient’s Concern: A 65-year-old man was brought to the emergency department for excruciating abdominal pain, vomiting and jaundice. He also had lower limb pitting edema and was hypotensive en route. Diagnosis: Congestive hepatopathy. Interventions: Intravenous furosemide and fluid restriction. Outcomes: The patient declined admission to the cardiology ward and discharged himself against medical advice after his condition was improved in the emergency department. Lessons: It is important to pay attention to acute abdominal pain induced by extraabdominal pathologies. In this case of acute decompensated congestive heart failure, early recognition of the cause makes a difference to the management.