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Suspected Fibromyalgia

27-year-old female with a diagnosis of suspected fibromyalgia. Her history includes long standing widespread musculo – skeletal pain connected to a feeling of general slight illness, as well as a series of accompanying symptoms: frequent migraines, cervicalgia, stomach disorders, chest pain and tachycardia . Therefore, she has carried out various follow-ups that each time detected a different problem for which the relevant therapy was set out.

Post traumatic pain in knee

A 37 years old female suffered from multiple traumas caused by road accident with admittance to emergency room- multiple contusions, cervicalgia(due to whiplash) and contusion-laceration injury to left knee. An MRI scan of the knee was performed two months later (MRI findings are attached below) and the patient was examined by a specialist who gave a diagnosis of medial meniscal tear and femur-kneecap pain in the left knee. A broken medial meniscus of the left knee diagnosis should lead to an arthroscopic operation.

Erectile Dysfunction in Diabetes

50-year-old male complaining of gradual appearance of erectile dysfunction up to absolute impossibility of even just a single erectile event. His medical history is significant for Type II Diabetes Mellitus and prostatitis. He started taking Cialis, Levitra, and then Viagra without obtaining any benefit. He underwent EMG of the inferior limbs and hematochemical examinations, that revieled signs of diabetic polyneuropathy, and possible superimposed lumbosacral radiculopathy. The possibility to give intracavernous penile injections has been proposed.

Left cervicobrachialgia following cervical discectomy

43-year-old male suffered of cervical disc herniation, and therefore C5-6 and C6-7 discectomy and fusion were done. About one year later he experienced acute sciatica followed by hot pricking sensation in the arm and neck. MRI showed far lateral bulge of L3-4 on the left and small disc bulge on C4-5, and a larger C5-6 disc herniation. Neurological examination disclosed C6-C7 radiculopathy on the left, minimal weakness of biceps and triceps muscles and reduced biceps reflex. EMG and physical examination were consistent with bilateral radiculopathy, attributed to small disc herniation.

Cervical Dystonia – additional opinion

47-year-old female with neck problems underwent Blink Reflex tests and EMG of the neck, and was diagnosed with cervical dystonia. Medical treatments available for cervical dystonia include anticholinergic therapy, Baclofen, or deep brain stimulation, but the mainstay of therapy remains botulinum toxin injections, which are considered the superior treatment for symptom control with less side effects in comparison to oral medications.

Low back pain due to spondylosis and degenerative disc disease

35 years old male. 3 years ago an episode of lumbar pain. After an X-ray test and lumbar spine MNR a disc herniation was diagnosed. Later on, disorders showed up sporadically, and 15 days ago, as a result of backache recurrence, the patient decided to carry out diagnostic deepening performing a new lumbosacral magnetic resonance and an electromyographic examination.

Severe Osteoporosis and Multiple Vertebral Fractures

82-year-old female with severe osteoporosis manifests with vertebral fractures. During treatment with Risedronate, she suffered another fracture. In the expert's opinion, taking into account the patient's age, the presence of fractures and low BMD, the patient is at a very high risk to develop a recurrent fracture so treatment must be given. The expert recommends to rule out secondary causes for osteoporosis such as vitamin D deficiency, to keep a healthy as possible way of life, and change the treatment with Risedronate to Forteo (Teriparatide).

Pain in the left knee

25-year-old male suffers from pain in his left knee that shows up after carrying out a limited physical activity. The length and the importance of the pain are proportional to the intensity of the physical activity, the pain is gradual, and is linked to the movement of the knee joint. Knee MRN showed misalignment of the femur and kneecap with the patella, diffuse superficial edema of the kneecap cartilage, and signs of diffuse tendinopathy. In the expert's opinion, the patient suffers from patello-femoral knee pain due to patellar malalignment or patellar maltracking.

Persistent Vertigo

47-year-old female who had the onset of persistent vertigo. The first evaluations revealed right beating nystagmus on gaze straight and to the right, unsteady gait with limb ataxia, and positive head thrust to the left. Improvement seemed to be occurring in that gait deviation with eyes closed was no longer present. Vestibular physical therapy exercises were started. On the next evaluations there was paroxysmal positional vertigo from the left ear and minimal neurosensory hearing loss. An audiogram showed minor neurosensory deafness.

Atrial Fibrillation at medium /high ventricular response_2

72-year-old male had a TIA in 1995 and has been in chronic atrial fibrillation since 1992. In 2005 2 ablative procedures were ineffective. The main treatment strategy for his atrial fibrillation has consisted of rate control and oral anticoagulation. Despite several attempts of different medications (digoxin, beta-blockers) he has remained in atrial fibrillation with a relatively moderate to fast ventricular response.

Mild Alzheimer’s disease – additional opinion

78-year-old male was diagnosed with possible mild Alzheimer’s disease. Medical history suggests a condition running a slow but steadily deteriorating course characterized by apathy as well as by impairment of memory, word finding difficulties and reduced vocabulary, impaired ability to make calculation and handle finances and difficulties in managing house work and going outside unsupervised. An episode with characteristics of delirium in the past is described as well. The neuropsychological evaluation describes moderate dementia.

Metastatic non small cell lung Cancer

67 year old male, previously a heavy smoker, suffering for 2 months from weakness, diminished appetite and weight loss. Tests showed a mass in right arm, possibly attached to muscle, and tenderness in right ribs. Chest CT showed a mass in LLL, lung foci, suspected secondary spread and masses in upper abdomen. CT guided biopsy from right lung mass was consistent with non small cell carcinoma with extensive necrosis. SPECT bone scan showed many focal findings in the vertebrae L,D2,7, most of the ribs bilaterally and in the limbs- suspected for secondary pathology.

Guillain-Barré Syndrome / Acute Myeloradiculoneuritis

45-year-old male who presented with acute onset of flaccid paraparesis more pronounced on the left, sensation of current shocks in both legs and sensory level from the umbilicus downwards. The symptoms have reached their pick within less than a day. On examination the left lower limb was plegic and the right lower limb was partially weak. EMG was interpreted as demyelinating sensorimotor neuropathy. MRI showed hyperintense signals at the dorsal terminal segment of the marrow consistent with myelitis.

Facial pain after thyroidectomy

A 47 years old female underwent total thyroidectomy for papillary carcinoma of the thyroid, followed by treatment with radioactive Iodine (I131).
Since then, the patient has been suffering from severe facial pain (left>right), dry mouth and recurrent local infections. She was diagnosed with bilateral sialadenitis, and was repeatedly treated with endoscopy and repeat washing. Medical treatment for neurogenic pain wasn't helpfull, as well as visits to different salivary gland specialists.

Wrist and Right Hand Pathology – additional opinion

47-year-old male has injured his right wrist while playing football 30 years ago. He always had some manageable pain while playing tennis. The pain increased during the last 12 months. The wrist CT scan that the expert recommended revealed diastasis between scaphoid and semilunar bone, palmar dislocation, dorsal intercalated segmental instability (DISI), marked radio-scaphoid arthritis and reactive sclerosis of the subchondral bone. This findings conformed the previous diagnosis of post traumatic osteoarthritis of radio-carpal joint brought upon by ligamentous injuries due to trauma.

Right Knee Pain

41-year-old male that in the past decade had suffered 2-3 times a year from bilateral knee pain which resolved spontaneously. Last year he had episodes of thumb pain that had lasted for several weeks and had affected grasp movements. The patient had responded to NSAID treatment for 2 weeks. MRI of the right knee showed Mild endoarticular effusion in the sub-quadriceps recess, chondropathy of the femoropatellar joint and lesion of the medial meniscus.

Left lumbosciatic pain from double disc protrusion

35-year-old female experienced an episode of lower back pain. Her doctor prescribed injections with Orudis, followed by further treatment with Voltaren. The treatment resulted in a simple remission of pain, that then re-appear at the same intensity as initially. The doctor established a new treatment that consisted of Indoxen and Bentelan. The patient experienced a remission of symptoms until even more intense lumbar pain returned spreading to the left leg. She recieved Voltaren, Muscoril, and Indoxen. Lumbar-sacral NMR showed disc central protrusion.

Psychomotor retardation due to spinal amyotrophy

10 months old, female. After normal birth (at the 40th week of pregnancy) and neonatal period, started to suffer from gastroesophageal reflux and recurrent respiratory infections, at times with broncospasm. In addition, psychomotor retardation was found and the young patient was assessed by a neurologist. The tests run (EMG and genetics for SMA) pointed to the diagnosis of Spinal Amyotrophy.
After hospitalization due to catarrhal bronchitis, the patient was discharged in good general conditions with recomendations for respiratory physiotherapy and neurological rehabilitation.

Possible Anorexia, Vomiting, Failure to Gain Weight and Linear Growth Retardation

21-month-old female who was born at almost 29 weeks weighing only 650g and with birth height of 31 cm. Her major problems have been poor feeding, failure to gain weight and linear growth retardation. The poor feeding has been handled by an NG tube and subsequently, food administration through a direct gastric tube via a gastrostomy. She gradually gained weight to the extent of being overweight for her height. Laboratory evaluation revealed low absolute numbers of neutrophils low lymphocyte count. Endocrynology and Genetics workup were normal.

Small Cell Neuroendocrine Tumor of the Cervix

36-year-old otherwise healthy female underwent routine tests that found atypical cells in Pap smear. Her cervix was biopsied, and found poorly differentiated neuroendocrine carcinoma. The findings of the PET-FDG test showed pathological absorption of FDG as a primary tumor of the cervix, towards the left side of the body. Moreover, evidence is seen of nodal metastatic spread in the retroperitoneum and pelvis. In the expert's opinion the patient has locally extensive small cell neuroendocrine carcinoma of the cervix with extensive pelvic and PA adenopathy.

Feeding problems, vomiting and short stature in prematurely born child

The patient is a 21 month old female who was born prematurely (at almost 29 weeks) weighing only 650g. She was released after 3 months from NICU, when she was 41 weeks old, weight 2kg. Her parents did not have any problems till she was 5 months old. Her major problems since have been: poor feeding, failure to gain weight and linear growth retardation. The poor feeding has been handled by an NG tube and later, food administration through a direct gastric tube via a gastrostomy.

End Stage Renal Disease

54-year-old obese male with end stage renal disease due to membranous nephropathy, has received 2 renal transplants in the past and is highly sensitized. He underwent coronary angiography for vessel CAD, and PTCAs and stanting were performed. His current treatment consists of multiple medications including mycophylate according to the instructions of his transplant nephrologist. His cardiologists sees no contraindication to transplantation.

Post infectious hypothyroidism

35-year-old female felt unusual tiredness a few months after giving birth, she gained weight and felt pain all over her body, paresthesias in her hands, and loss of energy. Examination revealed diffusely enlarged thyroid gland, the patient was clinically hypothyroid, and levothyroxine was prescribed. In the expert's opinion, the high TSH and low levels of T3 and T4 suggests the patient most likely suffers from Hashimotos thyroiditis and replacement with thyroid hormone can be a solution for her condition.

Pathology of the Wrist and Right Hand

47-year-old male has injured his right wrist while playing football 30 years ago. He always had some manageable pain while playing tennis. The pain increased during the last 12 months, and following this, MRI studies were performed. They revealed wrist Diastasis between scaphoid and semilunar bone in agreement with a lesion of the scapholunate ligament and pronounced radioscaphoid arthrotic manifestations. In the expert's opinion, the patient is suffering from post traumatic osteoarthritis of radio-carpal joint brought upon by ligamentous injuries due to trauma.

Renal Cell Carcinoma

53-year-old male complained of right flank discomfort. Scans revealed solid lesion with necrotic content in the left kidney, and radical nephrectomy with ipsilateral para-aortic lymph node dissection was performed. Pathology diagnosis was a clear cell renal carcinoma. The experts recommends a close routine follow up together with routine opthalmoscopy in order to detect retinal angiomas that can be an affect of VHL gene mutation.

Cerebral Atrophy

A 52 year old began having difficulties with balance. His problems evolved and he had been seen by neurologists providing clinical evidence for a cerebellar motor syndrome. The most recent examination showed ataxia, dysarthria, nystagmus, dysphagia and hyperreflexia. Although the disease has progressed the patient is not severely disabled at this time. 

 

Left lumbosciatic pain from L4-L5 and L5-S1 annular protrusion

The patient experienced an episode of lower back pain while carrying home shopping bags. Her family doctor diagnosed a “left lumbosciatic pain” and prescribed injections with vials of Orudis and Voltaren. The treatment resulted in temporary remission, therefore the patient started a new treatment regiment of Indoxen and Bentelan + acupuncture treatment which was partially beneficial.

Spinal column pathology - additional opinion

39-year-old male experienced in 1994 intense lower back pain after lifting weights, with spontaneous resolution. In 2006, he again experienced lower back pain radiating into both thighs. A lumbar MRI showed degenerative changes and EMG test showed L5 nerve root irritation. His physical examination demonstrated increased reflexes and a concern for cervical stenosis was entertained. Further cervical MRI and lumbar studies showed arthritic changes, and the thoracic MRI showed evidence of spinal cord compression. The surgeon suggested posterior thoracic laminectomy.

Acute Infectious Mononucleosis with Epstein-Barr Virus (EBV) – further opinion

Patient with clinical and laboratory picture compatible with acute infectious mononucleosis with Epstein-Barr Virus (EBV). Although he still feels weak, his condition is slowly improving. There is a gradual disappearance of the fever episodes and rash, in parallel with gradual normalization of the liver enzymes results, and disappearance of atypical lymphocytes. The reactivation of Herpes labialis can be explained by the stress involved in the EBV infection or the Cortisone treatment.

Metastatic, Non Small Cell Lung Cancer – further opinion

67-year-old with multiple co morbities: Heart, renal, vascular, hypertensive. His biopsy showed left lower lobe lung mass that was a TTF-1 Non small cell lung cancer- most likely an adenocarcinoma. Multiple small nodules < than 1cm were noted without certain etiology, together with “masses” in the upper abdomen and left arm. Recommended therapy includes single agent Vinorelbine.

Metastatic, Non Small Cell Lung Cancer

67-year-old with multiple co morbities: Heart, renal, vascular, hypertensive. His biopsy showed left lower lobe lung mass that was a TTF-1 Non small cell lung cancer- most likely an adenocarcinoma. Multiple small nodules < than 1cm were noted without certain etiology, together with “masses” in the upper abdomen and left arm. Recommended therapy includes single agent Vinorelbine.