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Cervical Disk Hernia_1

62-year-old male complained about sensation of pins and needles in the fingers accompanied by pain and feeling of pressure in the toes. The patient underwent CT and MRT of the cervical spine and conduction studies that showed signs of severe chronic neuropathy, Lordosis, disc hernias with pressure on the dural sac and narrowing of the canal together with segment myelopathy and spinal stenosis. In light of the weakness of the muscles in the patient's right hand, the expert recommendes a surgical solution.

Rectal Carcinoma, Gastric Carcinoma, Metastases.

52-year-old male was diagnosed in 2004 with a carcinoma of the lower rectum and underwent surgical anterior resection of the rectal tumor which was a well differentiated adenocarcinoma. In 2008 he underwent emergency operation for a perforated pyloric ulcer and then a radical resection of a gastric tumor which infiltrated the entire thickness of the gastric wall. It was a G3 diffuse type adenocarcinoma with signet ring cells, at pT3N2 stage.

Infiltrating basocellular carcinoma

72-year old woman noticed skin lesions at the internal orbital cantus of the right eye, diagnosed as infiltrating basocellular carcinoma with safe margins. The prognosis is good. A follow-up by a dermatologist is recommended.

Spinal pathology – additional opinion

75-year-old male with multiple complaints related to both his lumbar and cervical spine. He complains of low back pain, cramping and numbness in his thigh muscles, radiating left leg pain to his toes, as well as unsteady gait. He experiences numbness in his shoulders, arms and hands that gets worse over the day. He had a C4-5 fusion and a lumbar procedure at L4-5. The cervical MTI showed degenerative disease worse at C6-7 where there is moderate central and foraminal stenosis.

Spinal pathology

75-year-old male with multiple complaints related to both his lumbar and cervical spine. He complains of low back pain, cramping and numbness in his thigh muscles, radiating left leg pain to his toes, as well as unsteady gait. He experiences numbness in his shoulders, arms and hands that gets worse over the day. He had a C4-5 fusion and a lumbar procedure at L4-5. The cervical MTI showed degenerative disease worse at C6-7 where there is moderate central and foraminal stenosis.

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.

Bilateral Pronatory Syndrome Greater in the right foot – additional opinion

10-year-old female with pain and swelling of the right foot was diagnosed bilateral pronatory syndrome. The specialist recommended foot surgery for the lengthening of the Achilles tendon and application of retrograde endorthesis screw. The expert disagrees with the necessity of this procedure, and suggests differential diagnosis and conservative treatment that includes pain killers, soft shoes with soft insoles inside and mild elevation of the medial longitudinal arch of the feet.

Anterior chamber cleavage syndrome in right eye in a 2 months old infant

Infant female was diagnosed with anisocoria. "cornea of reduced size, anterior chamber nearly absent, anomalous iris marking, miotic pupil" were found in Ophthalmologic examination. Gonioscopy examination revealed posterior embryotoxon in both eyes, and bilateral "fibrous lobes" in the anterior chamber angle. There were also other anomalies found in the right eye.

Cystic Neoplasms of the Pancreas

The expert shares broad information regarding Cystic neoplasms of the pancreas: categories, symptoms, diagnosis, treatment, risks and outcomes, and qualifications for performing surgery on the pancreas.

 

Multiple miscarriages

31-year-old woman suffering from secondary recurrent abortions. During a 2 year period, she underwent 4 miscarriages with a thorough investigation, including genetic, anatomic, immune and thrombophilic testing. Nothing of significance has emerged to justify 4 miscarriages.

Left Knee Arthralgia

65-year-old female that suffers from pain in the left knee underwent examinations that showed femoral-tibial arthrotic manifestations, external degenerative meniscal tear and moderate joint effusion. A diagnosis of external degenerative meniscal tear was established. Further medical tests showed marked degeneration of the meniscal fibrocartilage, diffuse femoral-tibial arthrotic abnormalities, subchondral cysts and edema of the spongious bone, as well as rarefaction of the cartilage matrix, and manifestations of chondropathy.

Right and left lateral tibiotarsal instability

A 50 years old male with generalized ligamentous laxity and long history of distortions (Sprains) of the ankles. On the right ankle the incidence and severity of the sprains had increased significantly in recent months. On MRI imaging of both ankles: in the right ankle the lateral stabilizing ligaments are damaged and incongruent. On the left ankle the picture is similar with an old fracture of the tip of the medial malleolus which is not united, but not significantly displaced. Right ankle instability was diagnosed and  “Brodstrum“ type operation on right ankle has been suggested.

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.

Melanoma with metastases

47-year-old male with superficial malignant melanoma of the trunk. After excision of the lesion, a sentinel lymph node biopsy revealed lymph node involved with multi-focal microscopic subcapsular tumor. Subsequently, a lymphadenectomy was performed and the patient initiated treatment with interferon A. As a consequence, he developed marked lymphedemia of the right leg.

spreading pancreatic cancer

33-year-old female was diagnosed with multiple endocrine neoplasia of the pancreas. She underwent removal of the pancreatic lesion and lymph node dissection, another surgery to remove the distal pancreas and spleen, and parathyroidectomy, but the Octreoscan revealed recurrence.  

Long-term results of mandibular bone grafting operations

48-year-old male who had undergone multiple surgical attempts to augment mandibular bone for implant placement ('pins'). The patient received the opinion of a spesialist who spotted severe atrophy in the right mandibular posterolateral area. He reported on the condition of the mucosa with high insertion of frenii in the level of the alveolar ridge. Also the report related to occlusion problem and temporo mandibular dysfunction. In 2007, the patient received a report following a neurophysiological examination of the masseter muscle showing a change in sensation from the lower alveolus.

Giant Cell Epulis (peripheral giant cell granuloma)

86-year-old female presented to the clinic due to rapid growing T-formation on the mandible body in the frontal section, covering the body supra- and sub-mandibular, and was referred to a surgical biopsy procedure. Soft tissue was removed surgically by cutting out, and this Tumor over growth of gingiva and mandible bone was diagnosed as Giant Cell Tumor of Soft tissues.

Infiltrating Duct Carcinoma of Breast

51-year-old female underwent Lumpectomy and sentinel lymph node biopsy for infiltrating duct carcinoma of her left breast. The tumor was completely excised and concluded as stage I. The estrogen and progesterone receptor status were optimal, and therefore the expert recommends hormone therapy. He also recommends to complete the ongoing adjuvant irradiation program, to complete staging procedures, and to undergo genetic counseling.

Prostatic adenocarcinoma – additional information

78-years-old male with poorly differentiated hormone resistant prostate cancer. The expert recommends treatment with Ketoconazole as a "second line" hormonal treatment, together with LHRH agonist that he currently takes.

Incomplete Vitreous Detachment of the Left Eye

63-year-old female with clinical ocular history of mild myopia and presbyopia, started seeing floaters in her right eye, which worsened on the next day and were accompanied by photophobia. Examination revealed the existence of posterior vitreous detachment, with no evidence for retinal tear. Three days later she was examined again due to worsening of the symptoms and laser photocoagulation was performed at an area of suspected retinal traction. She still experiences the existence of floaters as well as light flashes.

 

B-cell lymphoma

59-year-old-male underwent biopsy, after founding epigastric mass, and was diagnosed with B-cell lymphoma. He was treated as an aggressive lymphoma with R-CHOP. Because of neurtopenia, the planned 6 cycle regimen was not completed and a radiation course was administered. Since then the patient feels well, but continues to have prolonged and persistent neutropenia with mild thrombocytopenia. The expert suggests differential diagnosis of the bone marrow problem, and recommends additional diagnostic workup.

Peripheral T-cell lymphoma

51-year-old male with past medical history that is remarkable for Sino-nasal adenocarcinoma which was resected 13 years ago, and a recurrent local tumor which was re-operated. Since late 2007, the patient has been noticed to have mild macrocytic anemia and leucopenia, and the hematologist thought it might represent a myelodysplastic syndrome.

Atrial fibrillation triggered by left foci and atrial flutter

p68-year-old male with recurrent asymptomatic paroxysmal atrial fibrillation underwent ablation of the cavo-tricuspidal isthmus. Holter exams showed sinus rhythm with brief and isolated episodes of atrial fibrillation, again with focal trigger. The choices of therapy are rate control, rhythm control, catheter ablation or antithrombotic therapy.

SOL (Space occupying lesion) of brain

33-year-old female underwent an episode of dizziness followed by speech disturbances and some right hand weakness. Her physical exam showed very mild signs of right cerebelar dysfunction. The MRI found mid-Vermian Cavernoma with clear signs of past bleeding and Bulging into the fourth ventricle. A surgery for resection of the cavernous malformation was recommended.

Valvular Heart Disease in Dissection of the Ascendant Aorta and Abdominal Aortic Aneurysm

72-year-old male with a diagnosis of mitral valve prolapse and chronic severe mitral regurgitation, aortic root and ascending aorta dilatation and patent foramen ovale. On 06/2008 he had dissection of the descending aorta. The clinical course has been characterized by hemodynamic stability and the vascular surgeon decided on conservative treatment and follow–up by thoracic CT.

Motor Neuron Disease – another opinion

72-year-old female developed progressive dysarthria and dysphagia. Her doctor describes her speech difficulty as “Spastic dysarthria with slow and nasal speech" and noticed decreased mobility in the tongue and palate. She underwent multiple investigations and started Rilutek. Since there is no biologic marker for ALS, the expert suggests further testing that is focused on trying to rule out other disorders and show diffuse lower motor neuron involvement

Multiple myeloma with renal involvement, bone lesions and Neuropathy

71-year-old-male had been diagnosed as having multiple myeloma (MM), apparently of the IgA-Lambda type, with renal involvement. The disease course is characterized by "ups and downs responding to anti-MM therapy. During the disease course, several problems and complications developed: Renal failure, Bone lesions and Neuropathy.

Sinus Tachycardia in Mitral Insufficiency

43-year-old female with history of continued cigarette smoking and complaints of palpitations. A sinus tachycardia of 160 is documented with little physical activity. Pulmonary function studies revealed obstructive ventilatory defects, consistent with the smoking or beta blockers. She has been documented to have moderate mitral regurgitation, consistent with prior rheumatic disease. At the present time, she is on Inderal.

Multirelapse Squamed Carcinoma of the Skin

75-year-old male with a cutaneous squamous cell carcinoma resected from the right eyebrow in 2003. In 2006, the patient underwent resection of an ipsilateral squamous cell carcinoma in the parotid bed that was presumably a nodal metastasis. He then experienced local relapse treated with resection and adjuvant radiotherapy. There was recurrent disease involving the right cheek excised in 2008. In 2009, another recurrence led to resection with orbital exenteration. Pathology showed squamous cell carcinoma, with perineural invasion, and extension into the orbital muscles.

Secondary Malignancy in mesentery following primary rectal cancer with multiple colonic polyps

69-year-old male found on colonoscopy to have multiple polyps and a rectal cancer. He underwent preoperative chemoRT, underwent resection and received a single cycle of bolus 5-FU with leucovorin. In early 2007, he had multiple complications and ultimately has a permanent ileostomy. Scans over the next few years have demonstrated nonspecific findings in his thorax however in July 2008 he had a mesenteric mass with adenopathy. These lesions had FDG uptake on PET scan.

Dental Case

60-year-old male was informed by the dentist that his 44th tooth would have to be removed. He would prefer to avoid the avulsion. The expert advises him to lose the tooth for the success of comprehensive prosthetic rehabilitation.

 

Thrombotic thrombocytopenic purpura (TTP) secondary to Systemic Lupus Erythematosus (SLE)

15 years old patient presented with clinical syndrome of fever, fatigue, and diarrhea. Laboratory findings showed severe anemia with findings of microangiopathic hemolysis (schistocytes, hyperbilirubinemia, elevated LDH) and severe thrombocytopenia. He was later documented to have fluctuating ADAMTS13 activity that appeared to correlate with the hematologic abnormalities. He also had urinary findings of hematuria, moderate proteinuria, and creatinine as high as 1.4 mg/dL.