Tuesday, June 7, 2016

Okay, now that I've got a couple medical experiences shared with all of you, how about we go back to the fun part where I share lots of pretty pictures of living on an island?

First, here's a picture of the occupation permit that I had been waiting on for quite some time- I officially began working on April 15th.

Along with receiving my working permit and legal residency, it was time to move out of my temporary housing at Port Chambly and head to a more permanent place to live. Here's a picture of the pool and the view from the top of the Address hotel looking toward the bay.

After a lot of searching I finally made the decision to move to Pereybere. It is in the northern area of the island, so it's close to the office where I work half of the week. The other half of the week I drive to Moka to work at Apollo Bramwell Hospital. Here are two pictures taken from outside of my small private apartment building (there are four living units in our building).

Lastly, here are two pictures taken from the 6th floor of the Apollo Bramwell Hospital in Moka. After a long morning of back-to-back patients with very interesting cases, sometimes it's nice to hop into the elevator and remember why I love working on this island.

Bonus pictures: The beach I can walk to in 5 minutes.

 The view from my apartment every morning.

A picture from the coastal jogs I try to do a few times per week in the morning.

Hope you enjoy the read and the view. Have a wonderful day!

I had another interesting case lately, this one is quick... but I think it's a good reminder for all of the new doctors/health professionals out there. If the presentation seems a bit wild, don't be scared to order imaging.

Case Report:

Patient presents with acute low back pain of 2 weeks duration and burning into both legs. Patient walks with two crutches. When patient had the problem last year he was never able to have the cortisone injection because of a heart problem (stroke). The back pain was small for some time but in the last two weeks it has been very extreme but he has been unable to walk, drive, etc and must use crutches. Patient has no issues controlling the bowels but notes that using the toilet is extremely painful because of the way he must maneuver to sit. This acute reinflammation came without warning for the patient. This time the pain is worse than it was a year ago. Pain killers are not really helping with the pain. When coughing or sneezing the pain is quite unbearable. Ice on the back helps for only a few minutes. Patient is unable to sleep due to the pain even when using pills to sleep. Burning into the legs. Denies burning or pain in the saddle distribution, but has burning down both legs. If patient doesn't move at all it can be a bit better for some time but easily inflames again if he moves.

Physical Examination finds slump test so strongly positive that the patient is unable to lift either leg while seated. Straight leg raise is extremely positive bilaterally before reaching 30 degrees. Kemp is so strongly positive that patient shakes in pain. Light palpation of the spine is horribly painful for the patient even in the seated position. Moving the patient into positions for examination is excruciatingly painful. Patient states today is the best he has been walking in 2 weeks (He is using two crutches and moving very slowly). There is no neurologic deficit noted in the reflexes, sensation, or motor activation of the lower extremity.

MRI of the Lumbar Spine from 27/01/2015 finds:

Mild anterior spondylolisthesis of  L5/S1.
L5/S1 discal bulging.
L3/ L4 right paracentral discal protrusion infenting on the right thecal sac & the right L4 nerve root .
Patient is sent for a new MRI of the Lumbar spine.

Patient arrives today seeming much better and is able to walk. He has brought along his MRI.

MRI Lumbar Spine 23/05/2016:

There is mild bulging of the L3 to S1 discs.
There is an abuttal of the right neural L3/L4 foramina indenting the anterior thecal sac at L4/L5 and L5/S1.
There is an abdominal aortic aneurysm (AP 4cm) noted with features of peripheral thrombus.

Patient's cardiologist was contacted and he was referred to him at this time.

Hi Everyone,

I've had a lot of crazy things happen recently (moving to a new place, dropping my laptop and breaking it, and I've been working hours like crazy). So, to apologize for my absence, I'm going to try to add lots of things to the blog today so that I can share some of the interesting things that I've been seeing here. Here's a small case report that I wrote up for my patient as I followed a very unique presentation:

Case Report:

Patient presented with history of cervical spine pain and Guillain-Barre syndrome. But in the last two months he has been having spasms that he feels in the upper thoracic spine and also in the chest. He has the feeling as if he may not be able to breathe (but he is able to keep breathing). Starts in the back, then squeezes at the chest, and then for some time it proceeds for 2-10 minutes. The first time it happened he was drinking a glass of water and it occurred when he bent forward a bit. Patient walks 4-5km per day and it can also happen during this time. Has stopped doing hard sports for the time being, used to be a big tennis player.

Physical Exam found upper extremity reflexes to be 2/5 bilaterally with no sensation loss. Lower extremity reflexes were found at 3-4+/5 bilaterally with no sensation loss bilaterally. S1 reflex on both sides had one beat of clonus and striking the right patellar reflex was sometimes able to produce a strong response in the opposite leg. Cervical ROM was not limited or provocative for any significant pain. When palpating the upper/mid thoracic spine that patient felt a sensation of heightened "pressure". Cervical flexion and cervical slump test reproduced pain in the upper thoracic spine.

At this time an MRI of the Dorsolumbar Spine was ordered in order to rule out space occupying lesion as a cause of the Upper Motor Neuron lesion symptoms demonstrated in the lower extremity; no cervical MRI was ordered due to the lack of upper extremity/cervical symptoms.

Patient has been worse with walking and sleeping. Cannot sleep on the left side, as soon as he moves his shoulders together the pain increases. Forward flexion is very difficult. Sleeping on the back is the best position. Notices pain in the lower neck. The problem seems to be related to forward flexion movements now, especially with the neck.

MRI of the Thoracolumbar spine shows no evidence of spinal cord compression or cause of myelopathy.

Physical exam now finds DTR 1/5 right bicep with sensory loss on the right C6/C7/C8 dermatomes. DTRs are 4/5 bilaterally in the lower extremity and these reflexes are increased with forward head flexion and decreased with extension of the neck. C7 spinous is extremely painful to palpation.
MRI of the Cervical Spine ordered at this time to determine the cause of the appearance of upper extremity Lower Motor Neuron lesion signs.

Patient returned with the results of the Cervical MRI. Has found that extending his neck during his episodes of spasm reduces the duration of them and he has had less spasms since he has started performing this movement. Patient admits to chronically "cracking" his own neck for the past few years.

MRI of the Cervical Spine finds osteo discal bars at the C3/4, C4/5, and C5/6 levels which are irritating the thecal sac.

Physical exam finds DTR 1/5 right bicep, sensation loss C6/C7 on the right, and DTR lower extremity 4+/5 that is reduced to 2/5 after 10x3 seated extension+retraction movements of the neck.
Due to the signs diminishing with movements in the extension and retraction motions, end of the table distraction coupled with extension and chin retraction was performed in three sets of ten. During this the patient had some discomfort at the cervicothoracic junction but afterwards there was no pain. Patient was instructed on how to perform seated extension and retraction exercises in order to monitor his symptoms and to call if there was any significant change.

At this point the diagnosis of Cervical Spondylosis with Myelopathy/Myelopathic signs was made. It is possible that the patient's chronic self-manipulation of the cervical spine could have contributed to the problem by creating an instability in the cervical spinal ligaments. This instability coupled with the osteo discal bars irritating the anterior thecal sac seem to be the cause of the motor neuron lesion signs that appeared during the examinations. It is also to remember this patient's history of neurologic disease. The patient is set to review again at the week's end on whether the symptoms change with the correctional exercise prescribed today. Patient was informed that if the symptoms do not reduce with corrective exercise that a surgical consultation may be necessary.

After last treatment patient felt okay for two days, then Wednesday was very sore and had some trouble. On Thursday he had no trouble at all even with lots of driving, moving, etc (only a bit of tension at the CT junction). Today he had some trouble in the morning but from 9:00am to 1:30pm there has been no issue. Consulted with the neurosurgeon and the neurosurgeon did not feel that the case was a surgical one. Patient is now able to sleep on his side. When he wakes up is when the pain is most important, but as soon as he returns to laying on his back the symptoms are relieved.

DTR 1/5 right bicep, sensation loss C6/C7 that recovers after allowing the head to stay in extension for about 30 seconds. DTR lower extremity 4/5 right more so than left that recovers to 2/5 after extension movement.

Advised the patient to continue with the extension movement as it both shows promise for his symptoms in the physical exam and he feels relief when performing this action. Patient recommended to seek consultation with neurologist at this time to comanage the case.