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Brain tumour as a cause of balance disorders

Background and purpose

Balance disorders and motion sickness are one of the most frequent reasons for consultation in Primary Care (almost 2% of the population at least once a year). Causes for these two symptoms are so numerous that it is difficult to list them all (benign paroxysmal positional vertigo, hypotension, arrhythmias…). This issue often makes us forget about some of the less frequent ones (and usually more dangerous), like brain tumours.

Case presentation

We present the case of a 40-year-old patient, with a medical history of multiple vertigos, migraine and cervical herniae, who comes to the Emergencies Service with a new episode of instability and motion sickness. After a thorough physical exploration and without manifesting any different symptom, it was sent home with the same treatment as always. Three days later, the patient consults again, this time suffering an episode of convulsions, syncope and loss of sphincter control. At his arrival, almost identical physical exploration as the last episode, but this time a CT Scan was requested, founding a cystic tumour on the sylvian aqueduct, causing obstructive hydrocephaly and so on, the balance disorder (after a quick surgical intervention the patient recovered without issues).

Conclusion

Even though the most frequent causes are the ones we have to think first, we can not forget about other possibilities, especially those ones who can put our patients at risk if we let them develop.

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Background: Violence has accompanied the evolution of humanity. It is defined as the “Intentional use of physical force or power, real or in the form of a threat, against oneself, against another person or against a group or a community, which results, or has the possibility of resulting, in injury, death, psychological damage, commitment to development or deprivation”.

Case description: Female, 66 years old, married and domestic. Inserted in a nuclear and uncontrolled family (phase VIII of the Duvall cycle), with APGAR Familiar of Smilkstein of 0 points. With a history of dyslipidemia, epilepsy, spine syndrome with irradiation of pain, malignant breast cancer, depression (with 2 previous hospitalizations for intentional drug intoxication).

She resorted to a scheduled consultation of primary care, with worsening depression and suicidal ideation by a conflicting marital relationship associated with domestic violence in verbal and physical form. On physical examination, no physical signs of aggression were observed. The patient refuses to report her husband and refuses support from Portuguese Association for Victim Support. Thus, it’s decided to refer the patient to the Emergency Department, where she was observed by Psychiatry. At the moment, the patient is under surveillance with Family doctor (FD), Psychiatry and Psychology.

Discussion: In Portugal, domestic violence is a public crime. Its reporting is mandatory for public officials. The case reveals the challenge to the FD in highlighting the breadth of care, proximity to the patient and provision of care centered on the individual and the family.

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Background and purpose

In UK general practice management of mild-moderate anxiety focuses on social prescribing.

Over two thirds of adults in the UK report feeling anxious about the impact that COVID 19 has had on their life. (1)

Drivers of this include social isolation, loss of coping mechanisms and reduced access to mental health services.

Prior to this these patients might have benefitted from group therapy, more face to face appointments and social support.

Methods

Aims to highlight the impact of COVID 19 on management of patients with health anxiety and role of social prescribing.

Two clinical cases :

Health anxiety exacerbated by restrictions, access to secondary care and bereavement.

Initial presentation with concerns about high blood pressure followed by right sided tinnitus. Both investigated and reassured by specialists.

Bereavement affected her support circle and she struggled to cope with COVID restrictions.

Multiple supportive consultations with reference to self help resources, psychology and mental health nurse input.

Anxiety, medically unexplained symptoms and EUPD.

Initial presentation with neurological symptoms.

Referred to a specialist.

Several further presentations with vague symptoms on a background of stress and anxiety.

Introduced to the concept of health anxiety with reference to social prescribing

Results

Introduction, case presentation followed by discussion about social prescribing and management.

Discuss and comparison between countries.

Conclusions

Helping patients with anxiety during the COVID pandemic is challenging due to limitations on services and mental health support.

GPs have an important role to empower patients and develop coping mechanisms through social prescribing.

Reference (1) : https://www.health.org.uk/news-and-comment/blogs/emerging-evidence-on-covid-19s-impact-on-mental-health-and-health?gclid=CjwKCAiAsaOBBhA4EiwAo0_AnBZOIwo1ZWj--thIurX_c4YL3tk79KOZltWZDflDpTwhAIB8AbkS-RoCi2MQAvD_BwE

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Background and purpose:
The postnatal period is described by WHO as one of the most critical phases of the lives of the mother and the newborn, however, is also one of the most neglected. This work tries to emphasize the importance of postpartum assessment.
Methods:
Data obtained from the patient’s clinical records.
Case Presentation:
A 35-year-old female, without any record of gynecologic pathology, one previous normal delivery in 2015, becomes pregnant at the end of 2019. The pregnancy was followed by her general practitioner, without complications. She had a vaginal delivery, in July 2020. About 10 days postpartum, the patient had her appointment at the health center. No reported issues, but still had lochia, mostly clear, rarely bloody, without signs of infection or pain. She chose not to initiate any contraceptive. About 20 days later, she returns reporting vaginal losses, sometimes of large amounts of blood. A pelvic ultrasound revealed a uterus with regular dimensions, regular myometrial structure, but with an endometrial nodular image, involving the anterior uterus wall, with cystic areas (dimensions of 45x30x59mm). Considering the ultrasound result and the fact that the blood loss was getting worse, the patient went to the ER, where the blood work revealed a β-hCG of 667804 mIU/mL. Later, a biopsy unraveled a choriocarcinoma, and the patient started the process of staging and treatment.
Conclusions:
Listening and discussing the body changes with the new mother is fundamental for a good practice and early diagnosis of birth related pathology.

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Background

Due to a new infection SARS-COV-2 which spread and caused a pandemic, there were reported unusual clinical cases among children. It appeared with manifestations of multisystem organ lesions, and severe conditions. Multisystem inflammatory syndrome is a rare condition affecting children with Covid 19 and post-infected children with the virus. The objective of the clinical case is to highlight MIS-C and complication with Steven Johnson's syndrome.

Case presentation

A 9 years old girl, presented to the hospital with high temperature 38-39C persistent for 6 days, fatigue, rush and conjunctivitis, plus it had been noticed vomiting and diarrhea for about 3-4 times.

Methods

Considering the clinical data of persistent fever, gastrointestinal symptoms (vomiting, diarrhea), rash, conjunctivitis followed by development of multisystem involvement (hepatitis, Covid-pneumonia, carditis, skin syndrome (thrombocytopenia), hypoproteinemia (nephrotoxic syndrome) and and laboratory data of lymphocytopenia, elevated inflammatory markers (C-reactive protein [CRP], procalcitonin, ferritine, erythrocyte sedimentation rate, D-dimer), and elevated creatinine were not excluded multisystem inflammatory syndrome diagnosis due to covid 19 exposure. Treatment was initiated with a high dose of corticosteroids, antibiotics, dopamine, skin antiseptic, oxygen therapy, later on the patient was put to ventilation, and blood transfusion.

Results/conlusions

The patient's condition was also complicated by the Steven Johnson syndrome that appeared due to antibiotic treatment. After 72 hours from hospitalization, there was the lethal outcome. General Practitioners should watch out to the symptoms mentioned before, especially during current pandemic situation among children, where the symptoms might lead to severe syndrome, with laboratory-confirmed SARS-CoV-2 infection or without, the latest suggests that MIS-C may represent a post-infectious complication of the virus.

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Background

COVID-19 is the disease caused by infection with the new Coronavirus (SARS-CoV-2) which, in severe cases, can justify hospitalization and often intensive care. However, after discharge, there are sometimes sequelae and situations of total or partial dependence, eventually requiring rehabilitation.

Case description

We will describe a case of a male, 78 years old, married, retired with a personal history of smoking (cessation 16 years ago) and complete bilateral hip replacement with the last surgical intervention in February 2020, complicated by DVT.

The patient went to the ER on March 31^st, 2020 for dyspnea, cough and fever. Patient stayed hospitalized until May 6^th, 2020 for SARS Cov2 pneumonia with possible bacterial infection. At the time of discharge, the patient had a pressure ulcer in the sacred region, myopathy associated with hospitalization, was weak and with significant motor deficits.

At home, clinical care, motor rehabilitation and training for caregivers were maintained until September 7^th, 2020 with clear clinical improvements, increased autonomy and quality of life.

Discussion

Faced with a situation of convalescence, the family doctor has a central role in assessing the impact that this may have on the illness of the convalescent person and on the family dynamics, looking at the patient in his context. In this case, the intervention of the family doctor proved to be of great importance in therapeutic management, clinical guidance, articulation and collaboration with other entities, namely social services and integrated continuous care team, to provide the best possible conditions for rehabilitation.

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Background

A cephalhaematoma is usually a benign condition which resolves spontaneously. Nevertheless, diagnosis of this condition is challenging between family doctors. The purpose of this work is to summarise risk factors, clinical criteria, pathogenesis, differential diagnosis, appropriate investigations and treatment methods for cephalhaematomas and its complications in infants.

Case presentation

A 2-week-old infant presented to the pediatric emergency room, referred by its family doctor, with a tender cephalhaematoma without local signs of inflammation, which had been worsening since delivery. The mass respected the sagittal suture lines, however a decision was made to ask for a transfontanelar ultrasound.

Later in the same shift, a 29-week-old infant presented to the same emergency, also referred by its family doctor, with a cephalhaematoma that remained the same size since the birth, however that showed recently, a very stiff presentation.

Conclusions

Diagnosis, differential diagnosis and management of different presentations of cephalhaematoma can be challenging to family doctors. Discussing real clinical cases on this common pediatric situation, red flags and differential diagnosis, might add a real value to family doctors daily practice, enhancing our knowledge and our confidence towards frequent conditions