Miscellaneous cases in adulthood

Chapter 29 Miscellaneous cases in adulthood



Case 29.1


During a routine visit, your patient, a 22-year-old man, reveals that he has noticed an enlargement of his left testis. It is not painful and is non-tender. He states that he was unaware of it until this week, so he has no idea how long it has been present.




Questions



1. Name at least two possible causes of his presentation.

2. How can you distinguish between these causes?

3. Does this patient require referral to a medical practitioner? How urgent is the situation? What investigations are required?

4. Describe the basic pathology for each of your differential diagnoses.


Case 29.2


John is a 25-year-old friend who asks for your advice regarding a pain in his penis. He intends to go to his medical practitioner, but wishes to prepare himself ‘for the worst’, as he assumes he has acquired a sexually transmitted infection. John states that it started as a mild discomfort, but worsened over the last few hours and is now extremely painful. He is reluctant to actually show you his penis, but nevertheless wants you to tell him what the condition is! He does describe his penis as being swollen and red at the distal end, and has noticed a small amount of urethral discharge. John also mentions that sometimes when he voids, his foreskin ‘balloons’ with a small quantity of urine.




Questions



1. What is your differential diagnosis?

2. For each of these diagnoses, compile a table which compares their aetiology and clinical manifestations.

3. What recommendations will you give John?


Case 29.3


You are sitting on a train and observe a woman sitting opposite you, who has a large, symmetrical, anterior, midline neck mass. The appearance is shown in Figure 29.1.


image

Figure 29.1


(Source: Mir, MA. Atlas of Clinical Diagnosis [2nd edn]. Edinburgh: Saunders; 2003: 133, Fig 6.20)




Questions



1. What anatomical structure is most likely the source of the mass? Why?

2. If she was your patient, what questions would you ask, and what would you examine, in order to:
a confirm the likely source of the mass

b assess the activity of the tissue mass.

3. What are the possible disorders which may result in the development of this mass?

4. What investigations would be most appropriate?


Case 29.4


A 50-year-old man has presented with weakness and deformity of one hand. His hand is shown in Figure 29.2.


image

Figure 29.2


(Source: Mir, MA. Atlas of Clinical Diagnosis [2nd edn]. Edinburgh: Saunders; 2003: 133, Fig 9.118–19)




Questions



1. Name the deformity shown in the photograph.

2. In what conditions may this deformity be found?

3. Describe the nerve supply of the intrinsic and extrinsic hand muscles.

4. For each of the following actions, name the muscles and nerves responsible for each.











































































Action Muscles responsible Innervation
Opposition of thumb    
Extension of thumb    
Abduction of thumb    
Flexion of thumb    
Adduction of thumb    
Flexion of fingers at MCP    
Extension of fingers at MCP joints    
Abduction of fingers at MCP joints    
Adduction of fingers at MCP joints    
Flexion of fingers at PIP joints    
Flexion of fingers at DIP joints    
Extension of fingers at IP joints    
Abducts little finger    
Flexes little finger    
Draws 5th digit forward and rotates it so it can meet the opposing thumb    
Flexion of hand    
Extension of hand    


5. Why is the clawing visible in digits 4 and 5 only?

6. Which muscles demonstrate atrophy?

7. What is Froment’s test? Will it be useful in this case?

8. Is his condition more likely to be a peripheral nerve lesion, or a spinal cord and/or nerve root pathology? Why?

9. Would there be any difference in clinical presentation if the damage to the nerve was at the elbow, or at the wrist? Why?

10. If there was sensory involvement, in which area would you expect to demonstrate hypoaesthesia or anaesthesia?

11. Draw two diagrams which illustrate:
a the dermatomal pattern of the upper limb

b the cutaneous distribution of the major branches of the brachial plexus.


Case 29.5


A 35-year-old man complains that he feels ‘something odd’ within the left side of his scrotum. He states that it is not painful, and is not an enlargement of his testis, and feels like thick pieces of spaghetti. It tends to disappear when he lies down.




Questions



1. What is the most likely diagnosis?

2. What structures are forming the ‘spaghetti’? What is the more common description for this disorder?

3. On which side is it more common? Can it be bilateral?

4. Why does it occur?

5. Can it affect fertility?


Case 29.6


A 27-year-old man presents with scrotal pain. It commenced 24 hours earlier as a mild discomfort, but has rapidly escalated to become very painful. He has also noticed some dysuria and urinary frequency over the last 48 hours. He also states that he has a fever. On examination, the scrotum appears erythematous and oedematous, and palpation of the scrotal contents on the left side is very painful for the patient. The testis and epididymis on the left side feels swollen, but it is difficult to ascertain which part is more tender.




Questions



1. What is your differential diagnosis?

2. Which of these differential diagnoses constitutes a surgical emergency?

3. Which investigation is usually performed to differentiate between them?

4. For each disorder named in question 1, state the possible aetiologies. What additional investigations may be required in each case?


Case 29.7


A 40-year-old woman presents with diffuse swelling of her right leg. It commenced 2 days ago, starting in her leg, and extended proximally up her thigh over this time period. There is no history of trauma, or any bites or stings. She has not travelled away from her home state for over a year. She states that the limb feels very heavy, and complains of discomfort rather than actual pain. On examination, the affected limb has a ‘dusky’ appearance and is warmer than her left lower limb. There are no sensory changes or motor weakness, all pulses are present, and there is a positive Homan’s sign. There is no tenderness of the limb.


Her leg is shown in Figure 29.3.


image

Figure 29.3


(Source: Mir, MA. Atlas of Clinical Diagnosis [2nd edn]. Edinburgh: Saunders; 2003: 215, Fig 11.11)




Questions



1. What is your first thought regarding the cause of the swelling? Explain.

2. What are other possible causes?

3. What pertinent questions should you ask to help you narrow your differential diagnosis?

4. What is Homan’s sign? How specific is this sign?

5. Will you refer this patient? Explain your answer.

6. The investigation confirmed your original diagnosis. Describe the pathophysiological basis of the oedema in this patient.

Related posts:

Eating disorders, substance abuse and behavioural disturbances in adolescence Fever in infancy and childhood Default ThumbnailPain in adolescence Miscellaneous cases in adolescence Altered mental state in the elderly Upper limb pain

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Dec 26, 2016 | Posted by in MANUAL THERAPIST | Comments Off on Miscellaneous cases in adulthood

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