BMJ case reports
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A 54-year-old man presented with recurrent episodes of transient ischemic attacks and acute stroke secondary to a floating thrombus in the right vertebral artery (VA) with narrowing of the right VA. He was initially treated medically with anticoagulation, antiplatelets and statins but developed multiple fresh infarcts. He was then referred for endovascular treatment, which was performed in a novel way.
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Central venous catheters are commonly used in the management of critically ill patients. This case report described a rare but potentially fatal complication of central venous catheter use. ⋯ On day 8 postoperatively he accidentally removed his catheter and collapsed with symptoms and signs suggestive of a cerebral air embolism. A transthoracic echocardiogram showed air bubbles in both the right and left ventricles of the heart confirming the presence of a paradoxical air embolism.
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Digital swelling is a common presentation in clinical practice. Patients presenting with swollen fingers to the emergency department will often have rings on their finger, which can be removed using a variety of simple non-operative techniques or by cutting the ring off and thus avoiding any long-term consequences. ⋯ We present an unusual case of patient with psychiatric illness who presented late with a ring that had embedded upon the volar aspect of the index finger. The difficulties faced by the emergency care practitioners in such circumstances, the consequences of rings acting as a tourniquet and strategies for removal of rings on swollen fingers are highlighted.
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A 39-year-old man (a lifetime non-smoker) presented with a locked left jaw and leg myoclonus. Clinical and electromyographic findings were in keeping with progressive encephalomyelitis with rigidity and myoclonus (PERM) syndrome. A thoracic CT scan demonstrated a 19 mm right hilar nodule, which was proven to be small cell lung cancer on bronchoscopic biopsy. ⋯ Symptoms were refractory to corticosteroids and IVIg therapy. Rituximab was then initiated, which led to a dramatic and sustained resolution of symptoms. To our knowledge, this is the first case of PERM related to antiglycine receptor antibodies from paraneoplastic syndrome, which resolved with rituximab.
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Case Reports
Wellens' syndrome: a classical electrocardiographic sign of impending myocardial infarction.
We describe a case of previously healthy 72-year-old man, who presented with rest angina. The ECG revealed sinus rhythm, biphasic T waves with preserved R waves in V1-V4 precordial leads. Subsequent evaluation revealed the normal serum cardiac marker levels and echocardiography with the coronary angiography showing a critical lesion in the proximal left anterior descending artery. ⋯ In our case, we highlight the subtle though classical ECG findings of Wellens' syndrome and its specific angiographic correlation. It can be of vital importance to identify these changes and intervene in time appropriately so as to avoid the development of myocardial infarction that carries a substantial morbidity and mortality. Important aspects of diagnosis and management have also been reviewed.