What would you do for plantar fasciitis?

Plantar fasciitis is a very common complaint that affects 10% of the general population at least once in a lifetime. Here's a video from the Mayo Clinic about what to do about it:

Can You Workout the Diagnosis? Can't walk, Can't talk and failed to respond to antifungals!!!

PRESENTING COMPLAINT

67 year-old gentleman with PMH of T2 diabetes, HTN, OA, bilateral knee replacement (2009) is referred to neurology services for evaluation of difficulty walking and slow progress in mobility after his knee surgery.

HISTORY OF PRESENTING COMPLAINT

The patient had 2 falls in the past 2 months. Progress with physios is very slow. Referred to his GP because of slow movement and slurred speech and symptoms of urinary frequency. GP prescribed antifungal treatment (no idea why? apparently his GP doesn't know that neurology exists;)

A month later, the patient experienced rapid decline of his mobility needing a walking stick initially and using a wheelchair currently. In his letter to neurology, the GP describes that patient is feeling his foot is glued to the floor and has enormous difficulty lifting it off.

Patient has occasional choking on bread and weight loss of 1 Kg over 6 months. But no smell, visual or taste problems. No problems with chewing, sleep disturbance. Upon further questioning, the patient also denies experiencing postural dizziness and there is no sudden bouts of uncontrollable laughter or crying (what do neurologists call this symptom? -Hint: common in patients with stroke)

OTHER HISTORY

Drug History - aspirin, amlodipine, omerprazole, insulin homologue

Family History - irrelevant

Social History - ex-smoker, drinks no alcohol

ON EXAMINATION

The patient appeared relaxed and slightly underdressed. Despite a room full of neurologists, he was very unnerved, and was joking and laughing. Dealing with audience questions, he would answer the question and then say 'Next'!!

His speech is slurred and dysarthric, better described as strangulated speech with words produced from the back of the mouth. In addition, there is an element of staccato speech when asked to say 'British constitution' or 'West Register Street'.

Gait- magnetic with a degree of stamping and difficulty of initiation. Stride is really slow at start, but improved slightly with 3rd and 4th step with increasing speed. Postural instability with stooped posture. Normal base.

CRANIAL NERVES

Normal range of eye movements. No restriction of upward gaze. No diplopia, squint or ptosis. Saccadic eye movement is normal. facial and mastication muscles are not weak or wasted. Absent jaw jerk. No wasting, fasciculation or weakness of the tongue. Rest of exam is also normal.

UPPER AND LOWER LIMB NEURO EXAM

Wasting and fasciculation of right wrist extensors. Tone is increased in upper and lower limbs - it is velocity dependent with a spastic catch. There is mild cogwheel rigidity in upper limbs. Global hyperreflexia (more predominant on R>L upper limbs). Positive Hoffman's reflex. No clonus and upper plantars are equivocal.

Finger-thumb test showed time-dependent reduction of velocity and amplitude of movement with 'fatiguability'.

No dysmetria, intention or resting tremors, dysdiadokokinesia or nystagmus.

INVESTIGATIONS

A number of investigations were performed. Results of investigations are provided upon your request.

What is the diagnosis? and Why?

Hint: Start by naming pathways in the nervous system, the involvement of which may account for this patients signs. Findings from the neuro exam should allow you to localize the lesion.

Johns Hopkins Comes to Kuwait!

This is very interesting. I posted a rant 10 days or so ago complaining how everyone in the Gulf except Kuwait is collaborating with world class hospitals. Someone must be reading our blog at the Ministry because yesterday, an article from KUNA stated that an agreement is being set up with Johns Hopkins to manage 4 Kuwaiti Hospitals (I'm joking, I don't really think anyone at the Ministry of Health is following our blog). This is fantastic! I love optimistic news. Read the article below:

Article from KUNA: -- Kuwaiti Health Minister Dr. Hilal Al-Sayer said Thursday that cooperation agreements have been set with John Hopkins University and Hospital, to manage Al-Farwaniya, Amiri, Addan and Jahra Hospitals in Kuwait.
Al-Sayer told Kuwait News Agency KUNA, that talks with John Hopkins officials included ways to provide technical support services, information systems, laboratories, radiology, and quality of services, in addition to reviewing work policies in technical divisions like emergency, anesthesia and surgery.
He added, discussions also included ways to develop the health sector in the four hospitals, in the fields of therapeutic, diagnostic and training, in addition to sending doctors from Kuwait for training and fellowship in subspecialties.
Al-Sayer said, officials at Johns Hopkins University aim to promote healthy relations with Kuwait, and is ready to provide all possible facilities and better health services.
The Minister of Health had signed a memo of understanding in Canada for the development of services to treat cancer diseases and surgery, in addition to cardiovascular research, education with the largest Canadian health centers and universities in Toronto and Montreal. (end) mah.st.asa KUNA 281344 Jan 10NNNN

Click here to read more

Test Your Clinical Knowledge!

What is the most appropriate liver test to exclude liver cell failure in a routine work-up in elderly patients, especially patients with dementia?

Don't miss: General Surgery Revision Course in RSM this weekend (Sat)

The Royal Society of Medicine near Oxford Road, London is a great resource of learning and clinical development. They have a variety of interesting and very useful revision courses for medical students not to mention a huge range of lectures and talks covering all relevant areas in medicine and surgery running constantly over the year.

I have attended a medical student revision day, which was very helpful indeed. They provide handouts and the speakers are very enthusiastic consultants in London. RSM headquarters is a nice building situated next door to the busy shopping place in Oxford Road. So, you can attend the course and go shopping afterwards!

I highly recommend the surgery course, especially for those of you who are interested in surgery and has finals coming up.

7 year old kid raises more than £150,000 for Haiti

This is really inspirational; seven year old Charlie Simpson decided to raise money for Unicef (who are collecting for Haiti) by doing a sponsored bike ride. He says on his justgiving page that he is, 'going to cycle around South Park as many times as possible…. (at least 10 laps, I hope!)' because he wants to, 'make some money to buy food, water and tents for everyone in Haiti'.

So far he has managed to amass £154, 284.50 (his original target was £500). You can sponsor Charlie here

I think community service should be given more importance in our culture. What do people think: do you think volunteering and community service is valued highly enough in Kuwait or should we be doing more?

How Not to Speak to your Patients!