A common practice in psychiatry when treating patients is the concurrent administration of anticholinergics along with antipsychotics, either to prevent or treat extrapyramidal syndrome reactions from occurring. However, most antipsychotics have inherent anticholinergic properties themselves. Therefore, this subtype of these patients have a higher than usual risk of developing anticholinergic side-effects, of which the central nervous manifestations can mimic psychosis, and may cloud judgement on patients' progress towards their treatment. KEYWORDS: Anticholinergics, anticholinergig toxicity, antipsychotics
Subtalar coalition is an uncommon condition that usually manifests in early adolescence(1). Frequently, this condition is missed. Delayed diagnosis may result in osteoarthritis requiring triple arthrodesis. Here, we report two patients with subtalar coalition. The first patient is a 12 year old boy who presented with right ankle pain for one year and was treated with excision of the coalition and bone wax insertion at the excision site. We followed up the patient for two years and the result was excellent with full range of movement of his right ankle and subtalar joint attained within two months. He returned to athletic activity by six months and was discharged with no complications after two years. The second patient is a 15 year old girl who presented with bilateral ankle pain and swelling for three years and was treated with excision of the coalition and subtalar interpositional arthroplasty bilaterally. She defaulted follow up after seven months as she was very satisfied with the result. We wish to highlight this condition which may be misdiagnosed as flexible flat foot or ankle sprain.
Many cluster headache (CH) patients waited several years to be accurately diagnosed because their symptoms are often mistaken for sinusitis or a dental disorder.1 Patients have also been mistakenly diagnosed as analgesic drug abusers or suffering from a psychiatric illness. This case report illustrates how a young lady was diagnosed to have cluster headache after several years of consultations with ophthalmologists for eye swelling and redness. It also highlights the importance of pain assessment and a general and holistic approach to medical care which is the main distinguishing feature of Family Medicine.
Treatment refusal is a common encounter in clinical practice. The process of deciding to refuse treatment is often complex. It is our responsibility to try and understand this process of decision making and the underlying reasons for treatment refusal. Many of these reasons are often rational in the context where the decision is made. The patients could be making the best decision for themselves even if these decisions are not necessarily the best in our mind. We should at all times discuss our treatment options and assess their ability to make decisions in achieving common goals. These goals should balance our best treatment strategies and the patients' best interest. This article discusses the reasons underlying treatment refusal and how we can achieve a common goal with our patients.
Giant cell tumor (GCT) of the craniofacial bones has been reported but they are not common. This tumor occurs more often in women than in men and predominantly affects patients around the third to fifth decade of life. GCTs are generally benign but can be locally aggressive as well. We report a case of GCT involving the temporomandibular joint (TMJ), which was initially thought to be temporomandibular disorder (TMD). A 22-year-old female presented with swelling and pain over the right temporal region for 18 months associated with jaw locking and clicking sounds. On examination, her jaw deviated to the right during opening and there was a 2×2 cm swelling over the right temporal region. Despite routine treatment for TMD, the swelling increased in size. Computed tomography and magnetic resonance imaging of the brain and TMJ revealed an erosive tumor of the temporal bone involving the TMJ which was displacing the temporal lobe. Surgical excision was done and the tumor removed completely. Histopathological examination was consistent with a GCT. No clinical or radiological recurrence was detected 10 months post-surgery.
A common practice in psychiatry when treating patients is the concurrent administration of anticholinergics along with antipsychotics, either to prevent or treat extrapyramidal syndrome reactions from occurring. However, most antipsychotics have inherent anticholinergic properties themselves. Therefore, this subtype of these patients have a higher than usual risk of developing anticholinergic side-effects, of which the central nervous manifestations can mimic psychosis, and may cloud judgement on patients’ progress towards their treatment.
Six patients underwent transcatheter closure of patent ductus arteriosus (PDA) using either conventional Gianturco coils or the Amplatzer Ductal Occluder (ADO) device. All patients were females with a median age of 23.3 (range 4 to 26 years). The mean PDA size measured on the lateral aortogram was 3.81mm (range 2.3-5.83mm). Complete closure of the PDA was achieved in all patients.
The phenomenon of 'lost fetus' to orang bunian is quite commonly heard of in our culture. It may present in psychiatric settings and may potentially create confusion and difficulties in diagnostic and management aspects. A case of feigned full-term pregnancy followed by a pregnancy loss is described. This review emphasizes the need to recognize this phenomenon of 'lost advanced pregnancy' in context of the Malay belief. Possible etiological factors, diagnostic indicators of factitious disorder and management strategies are discussed. The possibility of cultural beliefs being used as psychological defenses is also discussed. Keywords: lost pregnancy, orang bunian, Malay mystical belief, factitious disorder
Complicated migraine is not well known. It is associated with transient and protean sensory and motor
nenrological features although disturbance of mood, affect and psyche has also been described.
This paper is based on a study of ten patients suffering from complicated migraine and attempt is made
to describe various neurological symptoms and signs.
It becomes apparent from this study that there arc diverse manifestations of this interesting disorder.
Furthermore complicated migraine seems to affect a younger age group and there may not be any
family history of migraine. In most cases the nenrological symptoms precede the attacks of headaches.
The nenrological deficit may persist after longer periods. Initially, the attacks arc usnally followed by
complete recovery, with repeated attacks there may be residual neurological deficit. Though the exact
aetiology of the migraine remains unknown, it has been suggested that it is due to spasm or oedema of
cerebral vascular system. If the vessels involved are the carotid artery system, the symptoms and signs
obviously would be due to involvement of cerebral hemisphere, whereas affection of basilar artery
would produce signs and symptoms of cerebellar or brain stem deficiency.
At times it may be extremely difficult to differentiate between a typical attack of migraine and headache
due to an underlying pathology e.g. intracranial angioma or space occupying lesions, which may
require investigations such as angiography. The angiography may prove fruitless and cause deterioration
in neurological signs. A careful follow-up should be planned for cases with complicated migraine
to exclude any underlying pathology.
Generally, clinical presentations of Graves' disease range from asymptomatic disease to overt symptomatic hyperthyroidism with heat intolerance, tremor, palpitation, weight loss, and increased appetite. However, atypical presentation of Graves' disease with hematological system involvement, notably pancytopenia, is distinctly uncommon. Hereby, we present and discuss a series of three untreated cases of Graves' disease clinically presented with pancytopenia and the hematological abnormalities that responded well to anti-thyroid treatment. With resolution of the thyrotoxic state, the hematological parameters improved simultaneously. Thus, it is crucial that anti-thyroid treatment be considered in patients with Graves' disease and pancytopenia after a thorough hematological evaluation.
Polypoid endometriosis is an uncommon variant of endometriosis which can mimic malignancy due to its presentation as masses. We present a case of polypoid endometriosis which simulated cervical malignancy both on clinical examination and on computed tomography (CT) scanning and discuss how magnetic resonance (MR) imaging, in particular Diffusion Weighted Imaging (DWI), can help to distinguish this condition from true malignancy and avoid invasive surgery.
Hypersensitivity to stainless steel sternal sutures are an uncommon occurrence. We present a case of such a patient who developed chronic tissue overgranulation over a sternotomy wound eight weeks post-operatively. Primary suspicion was infection, a more common complication however radiological and laboratory investigation showed otherwise. Conservative management provided limited ephemeral success. After ensuring adequate sternal bone healing, the sutures and granulation tissue were eventually surgically removed without complication and the reoperated wound healed well.