1/31. facial nerve palsy secondary to internal carotid artery dissection.We report facial palsy as the sole cranial neuropathy complicating an ipsilateral internal carotid artery dissection. A previously healthy 44-year-old man developed retro-orbital and temporal headache with associated nausea while engaged in modest physical exercise. On the following morning he noticed a left ptosis and miotic pupil. One week later he woke with a left facial weakness. On the same day he had a 90-minute episode of expressive dysphasia. magnetic resonance imaging and angiography demonstrated left internal carotid artery dissection. The temporal association between our patient's facial nerve palsy and typical features of spontaneous internal carotid artery dissection suggests a common aetiology. We suggest that involvement of the VII cranial nerve in isolation followed disruption of an anomalous nutrient artery. The delay in clinical manifestation may imply extension of the dissection.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
2/31. Treatment of major depression complicated by bilateral foot drop and double incontinence with ECT.This report describes a 56-year-old man with severe depression who developed bilateral foot drop, dual incontinence, and swallowing difficulties, which required several physical investigations and consultations before an excellent response to electroconvulsive therapy occurred with reversal of all symptoms.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
3/31. Treating aerophagia with contingent physical guidance.Contingent physical guidance was used to treat chronic aerophagia. This consisted of guiding the participant's hand over her mouth following each attempt to engage in aerophagia. A wristwatch was then correlated with the contingent physical guidance procedure. Responding remained low in the presence of the wristwatch, even after contingent physical guidance was withdrawn.- - - - - - - - - - ranking = 7keywords = physical (Clic here for more details about this article) |
4/31. Oral extrusion of a screw after anterior cervical spine plating.STUDY DESIGN: A case report of a 76-year-old woman who retched up a screw from a cervical spine locking plate 5 years after anterior cervical spine fusion. The literature relevant to this topic is reviewed. OBJECTIVES: To report the rare but potentially life-threatening complication of oral screw extrusion after anterior cervical spine plating, to review the relevant literature on the topic, and to discuss the clinical management of instrumentation failure in anterior cervical spine plating. SUMMARY OF BACKGROUND DATA: Anterior cervical spine fusion and stabilization is a well-established procedure. Complications include instrumentation failure, which can progress to extrusion through the gastrointestinal tract. Management is dependent on the severity and progression of clinical and radiologic signs and symptoms. reoperation should be considered in certain cases. methods: A rare complication of anterior cervical spine plating in a 76-year-old woman 5 years after the initial operation is reported. The patient was assessed with serial physical examination and radiograph and one further follow-up 3 months after the first presentation. RESULTS: The patient was asymptomatic shortly after she retched up the screw, and at the 3-month follow-up was without evidence of progression of plate dislodgement. CONCLUSION: As reported, oral extrusion of cervical spine grafts or instrumentation is rare but potentially serious. Each case of instrumentation failure should be assessed individually to decide if conservative management is appropriate or if reoperation should be considered.- - - - - - - - - - ranking = 7.9882736973287keywords = physical examination, physical (Clic here for more details about this article) |
5/31. Diffuse idiopathic skeletal hyperostosis: a case of dysphagia.OBJECTIVE: To present and discuss the clinical manifestations, radiographic features, and treatment of a patient with diffuse idiopathic skeletal hyperostosis complicated by dysphagia. This case serves as an educational tool by bringing attention to an uncommon complication of a common disorder. An emphasis is placed on diagnostic imaging. CLINICAL FEATURES: A 63-year-old man had dysphagia after a fall from a ladder. Plain film radiographs revealed large flowing hyperostoses arising from the anterior aspect of C3-6. Advanced imaging, consisting of a computed tomography (CT) scan and a modified barium-swallow study were performed to provide additional anatomic and functional information. INTERVENTION AND OUTCOME: Treatment provided by a speech and language pathologist focused on the dysphagia and consisted of compensatory management for 2 weeks. The patient was able to successfully swallow pur ed food and was released with instructions to modify his diet as tolerated. CONCLUSION: Dysphagia is a common clinical presentation for many disorders of deglutition. Flowing spinal hyperostoses such as that seen in diffuse idiopathic skeletal hyperostosis may become large enough to physically encroach on the pharynx or esophagus or indirectly predispose the patient to swallowing problems from posttraumatic edema. Conservative care is the initial treatment of choice, whereas surgical excision of the hyperostoses is reserved for difficult cases.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
6/31. Cognitive presentation of multiple sclerosis: evidence for a cortical variant.BACKGROUND: Although neuropsychiatric complications are well recognised, the presentation of multiple sclerosis with cognitive or neuropsychiatric symptoms has generally been considered a rare occurrence and to reflect subcortical pathology. OBJECTIVES: To document the clinical, neuropsychological, and radiological features of six cases of cognitive presentation of multiple sclerosis, to review the relevant literature, and to propose a possible cortical basis for this clinical presentation. SUBJECTS: Six patients (five women; age range 38 to 60 years) presented to the memory and cognitive disorders clinic in Cambridge with an initially undiagnosed cognitive/neuropsychiatric syndrome. All underwent neuropsychological evaluation, brain imaging, and ancillary investigations to establish a diagnosis of multiple sclerosis. RESULTS: The six cases all had a progressive dementia syndrome with prominent amnesia, often accompanied by classic cortical features including dysphasia, dysgraphia, or dyslexia. Mood disturbance was ubiquitous and in three patients there was a long history of preceding severe depression. All six developed characteristic physical signs on follow up, with marked disabilities. A review of 17 previously reported cases highlighted the prominence of memory impairment and depression in the early stages. CONCLUSIONS: On clinical, pathological, and radiological grounds, the neuropsychiatric presentation of multiple sclerosis may represent a clinicopathological entity of "cortical multiple sclerosis." Failure to recognise this will delay diagnosis and may expose patients to potentially dangerous and invasive investigation. Because the neuropsychiatric features of cortical multiple sclerosis are a major cause of handicap, their early recognition may be particularly important in view of emerging treatments.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
7/31. Cases from the Osler Medical Service at Johns Hopkins University. diagnosis: P. carinii pneumonia and primary pulmonary sporotrichosis.PRESENTING FEATURES: A 53-year-old man who had human immunodeficiency virus (hiv) presented to the Johns Hopkins Hospital with a 3-month history of increasing dysphagia, cough, dyspnea, chest pain, and an episode of syncope. His past medical history was notable for oral and presumptive esophageal candidiasis that was treated with fluconazole 6 months prior to presentation. Three months prior to presentation, he discontinued his medications, and his symptoms of dysphagia recurred. During that time he developed intermittent fevers and chills, progressively worsening dyspnea on exertion, and a cough productive of white sputum. He also reported a 40-lb weight loss over the past 3 months. On the day prior to presentation, he had chest pain and shortness of breath followed by weakness, dizziness, and a brief syncopal episode. He denied orthopnea, paroxysmal nocturnal dyspnea, lower extremity edema, jaundice, hemoptysis, hematemesis, melena, hematochezia, or diarrhea. There was no history of alcohol use, and he stopped smoking tobacco approximately 1 month previously. He smoked cocaine but denied injection drug use. The patient had never been on antiretroviral therapy and had never had his CD4 count or viral load measured. On physical examination, the patient was a thin, cachectic man who appeared older than his stated age. His vital signs were notable for blood pressure of 102/69 mm Hg, resting tachycardia of 102 beats per minute, resting oxygen saturation of 92% on room air, normal resting respiratory rate, and a temperature of 38.1 degrees C. His oropharynx was clear, with no signs of thrush or mucosal ulcers. His pulmonary examination was notable for diminished breath sounds in the lower lung fields bilaterally. Cardiac, abdominal, and neurologic examinations were normal. His skin was intact, with no visible petechiae, rashes, nodules, or ulcers. Laboratory studies showed a total white blood cell count of 3.2 x 10(3)/microL, with a total lymphocyte count of 330/microL, hematocrit of 30.2%, a serum sodium level of 129 mEq/L, and a serum lactate dehydrogenase level of 219 IU/L. The patient had an absolute CD4 count of 8 cells/mm3 and a hiv viral load of 86,457 copies/mL. His arterial blood gas on room air had a pH of 7.51, a PCO2 of 33 mm Hg, and a PO2 of 55 mm Hg. Electrocardiogram and serial serum cardiac enzymes were normal. A chest radiograph showed bilateral upper lobe patchy infiltrates with left upper lobe consolidation. Computed tomographic (CT) scan of the chest with contrast showed bilateral ground glass infiltrates with focal consolidation (Figure 1) and no evidence of pulmonary embolism. Induced sputum was negative for pneumocystis carinii, fungi, or acid-fast bacilli. A bronchoalveolar lavage was performed. What is the diagnosis?- - - - - - - - - - ranking = 7.9882736973287keywords = physical examination, physical (Clic here for more details about this article) |
8/31. Pediatric caustic ingestion and parental cocaine abuse.OBJECTIVE: To report two cases in which toddlers drank a caustic liquid which their parents had been using to prepare free-base and crack cocaine. DESIGN: Case series. RESULTS: Two toddlers presented with first- and second-degree burns of the oral cavity, pharynx and esophagus from caustic ingestion. The first had drunk ammonia from an unmarked clear plastic container the morning after "a party at a friend's house". The second had drunk potassium hydroxide from a clear plastic container which was labelled "pH UP" and had a small "Danger" sign. Both children were treated with intravenous hydration, steroids, antibiotics and analgesics. Fortunately, neither child suffered long-term physical sequelae. When questioned, the parents of both children admitted to using these alkalis to prepare free-base and crack cocaine. Appropriate steps were taken by social services to protect these children from further neglect. DISCUSSION: Despite federal legislation and public education, pediatric caustic ingestion remains a significant problem. These cases suggest that, in certain cases of pediatric caustic ingestion, caregivers should be questioned regarding possible drug abuse. Larger warning labels and further public education might help prevent many cases of pediatric caustic ingestion.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
9/31. Bilateral peritonsillar abscesses: not your usual sore throat.We describe a rare case of a previously healthy 30-year-old man who presented to the Emergency Department (ED) with bilateral peritonsillar abscesses. The clinical presentation of fever, trismus and odynophagia was consistent with pertonsillar abscess (PTA), but the presence of symmetric tonsillar swelling and midline uvula confounded the diagnosis. The true incidence of bilateral peritonsillar abscesses is unknown, but the incidence of unsuspected contralateral peritonsillar abscess identified at tonsillectomy has been reported to be between 1.9% and 24%. The diagnosis of bilateral peritonsillar abscesses should be considered when the clinical presentation suggests the diagnosis of PTA, but the physical examination reveals bilateral swollen tonsils with a midline uvula.- - - - - - - - - - ranking = 7.9882736973287keywords = physical examination, physical (Clic here for more details about this article) |
10/31. Haemodynamic instability during transhiatal resection of oesophagus results in postoperative metabolic acidosis and hypoxia: is there a need for assisted ventilation?Oesophagectomy for oesophageal carcinoma is a stressful physical and metabolic challenge for an individual. The metabolic acidosis and hypoxia resulting postoperatively in a 34-year-old male, suffering from oesophageal carcinoma, after transhiatal oesophagectomy was managed without assisted ventilation contrary to the usual teaching. Relevant literature has been reviewed.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
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