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differential diagnosis

An Evidence-Based Approach to the Neck Assessment

Teaser: 

Dr. Julia Alleyne, BHSc(PT), MD, CCFP, Dip. Sport Med MScCH1 Pierre Côté, DC, PhD2 Dr. Hamilton Hall, MD, FRCSC3

1is a Family Physician practising Sport and Exercise Medicine at the Toronto Rehabilitation Institute, University Health Network. She is appointed at the University of Toronto, Department of Family and Community Medicine as an Associate Clinical Professor. 2Professor and Canada Research Chair in Disability Prevention and Rehabilitation, Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT); Director, UOIT-CMCC Centre for Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC). 3 is a Professor in the Department of Surgery at the University of Toronto. He is the Medical Director, CBI Health Group and Executive Director of the Canadian Spine Society in Toronto, Ontario.

CLINICAL TOOLS

Abstract:Neck pain is a common musculoskeletal condition that frequently resolves spontaneously or with conservative treatment and only occasionally requires surgical intervention. The purpose of the neck examination is to determine if the etiology is neurological or mechanical pain, which determines treatment planning, and then to rule out red flags. There is good evidence that on examination clinicians cannot reliably differentiate specific anatomical structures but they should still perform a focused clinical examination to locate typical pain on movement and establish the neurological status. Base treatment on exercise, activity management and pain control.
Key Words: neck, examination, treatment, differential diagnosis.

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If your patient is presenting with symptoms of systemic disease, deteriorating neurological status or focal severe pain, initiate further investigations and or referral.
Once red flags have been ruled out, neck pain will fall into two categories: neurological or mechanical pain.
Range of Motion testing should be done in 3 specific planes; flexion-extension, lateral flexion and rotation. Moving the neck in circles does not provide useful clinical information.
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Diagnosis and Management of Progressive Supranuclear Palsy

Diagnosis and Management of Progressive Supranuclear Palsy

Teaser: 

Amitabh Gupta, MD, Clinical Fellow, Movement Disorders Centre, Toronto Western Hospital, University of Toronto, ON.
Susan Fox, MD, Assistant Professor, Movement Disorders Centre, Toronto Western Hospital, University of Toronto, ON.

Progressive supranuclear palsy (PSP) is a rare, fatal neurodegenerative disease with limited treatment options that is characterized by gait and postural instability and a classical vertical supranuclear gaze palsy. Initially often misdiagnosed as idiopathic Parkinson’s disease (IPD), proper patient care in PSP may be delayed until late into the disease course, after dopaminergic medication fails to improve symptoms. Here, we review the diagnostic criteria that help to separate PSP from IPD and rarer forms of parkinsonian diseases to help clinicians with earlier recognition. We discuss current treatment concepts as well as ongoing experimental approaches that are derived from an emerging pathological understanding.
Key words: progressive supranuclear palsy, clinical diagnosis, imaging, differential diagnosis, management.

Pitfalls in the Diagnosis of Dementia

Pitfalls in the Diagnosis of Dementia

Teaser: 

The accredited CME learning activity based on this article is offered under the auspices of the CE department of the University of Toronto. Participating physicians are entitled to one (1) MAINPRO-M1 credit by completing this program, found online at www.geriatricsandaging.ca/cme

Lonn Myronuk, MD, FRCPC,
Member of the Canadian Academy of Geriatric Psychiatry; President, GeriPsych Medical Services, Inc., Parksville, BC.

Progress in basic neuroscience has brought disparate clinical phenotypes of dementia together in categories based on common pathophysiological processes. Degenerative dementias are all proteinopathies featuring abnormal processing and CNS accumulation of different proteins in different neuroanatomic distributions dictating patterns of presentation of clinical symptoms and potential responsiveness to treatment. Alzheimer’s disease (AD) is an amyloidopathy. Dementia with Lewy bodies (DLB), Parkinson’s disease (PD) and multiple system atrophy (MSA) are synucleinopathies. Frontotemporal lobar degeneration (FTLD), progressive supranuclear palsy, and corticobasal degeneration are tauopathies. Vascular dementia (VaD) has been considered a distinct pathophysiologic process yet may exist on a continuum with AD. Currently available dementia treatments are not specific for a single disorder, yet not all dementias are treatment responsive. Exclusion of otherwise treatable depressive disorders and metabolic derangements as well as surveillance for deleterious cognitive effects of medication remain central to the assessment and treatment of the older adult with cognitive complaints. Identification of those syndromes for which certain medications may be contraindicated, as well as those that may be selectively responsive to particular compounds, will continue to increase in importance as our range of therapeutic options widens over the coming years.
Key Words: Alzheimer’s disease, Lewy body, frontotemporal lobar degeneration, vascular dementia, differential diagnosis.

Diagnosis and Prevention of Delirium

Diagnosis and Prevention of Delirium

Teaser: 

James L. Rudolph, MD, SM, Division of Aging, Brigham and Women's Hospital and the Boston VA Geriatric Research, Education, and Clinical Center, Boston, MA.

Edward R. Marcantonio, MD, SM, Hebrew Rehabilitation Center for Aged and Beth Israel Deaconess Medical Center, Boston, MA.

Delirium is a common syndrome in hospitalized older patients that is frequently undiagnosed by health care professionals. This is particularly troubling because delirium is associated with poor outcomes such as increased nursing home placement, nosocomial infections and increased mortality. Criteria for the diagnosis of delirium are validated, reliable and can readily be applied to patients by health care professionals. Solid evidence exists that delirium can be prevented with educated prescribing of medications, practical in-hospital interventions and geriatric consultation.
Key words: delirium, differential diagnosis, prevention, Confusion Assessment Method.

Considerations in the Management of Epilepsy in the Elderly

Considerations in the Management of Epilepsy in the Elderly

Teaser: 

Warren T. Blume, MD, FRCPC, London Health Sciences Centre, University Campus, Epilepsy Unit; Professor, University of Western Ontario, London, ON.
David J. Harris, LRCP(Lond), MRCS(Eng), FRCPC, MRCPsych, London Health Sciences Centre, South Street Campus, Geriatric Mental Health Program; Associate Professor, University of Western Ontario, London, ON.

Management of epilepsy in an elderly person requires accurate classification of seizures, a sufficient neurologic assessment to define etiology, and awareness of the patient's health and social situation. Treatment with an antiepileptic drug requires an understanding of the general health of the patient and the nature of all medications being given to the patient by other physicians. Effective communication with the patient, spouse, any adult children or other caregivers aims to ensure that all understand the goals of treatment, medication side effects and monitoring methods. Concomitant illness such as neurological, psychiatric, metabolic or cardiac disorders will require individualization of treatment plans.
Key words: epilepsy, elderly, differential diagnosis, management.

Inflammatory Bowel Disease in the Elderly

Inflammatory Bowel Disease in the Elderly

Teaser: 

Alexander I. Aspinall, MD, PhD and Jon B. Meddings, MD, FRCPC, Division of Gastroenterology, Faculty of Medicine, University of Calgary, Calgary, AB.

The inflammatory bowel diseases (IBD)--Crohn's disease (CD) and ulcerative colitis (UC)--have a second peak of onset after the age of 60. Discerning IBD from alternate diagnoses is a great challenge in the geriatric population, as other diseases commonly encountered in the elderly can mimic IBD. The possibilities include ischemic colitis, diverticulitis and infectious colitis. Diagnosing and treating IBD should involve consultation with a gastroenterologist, but the approaches do not vary significantly from the strategies used in younger patients. Therapeutic modalities used in younger age groups are also applicable to the geriatric population, but great attention needs to be given to side effects and drug interactions.
Key words: inflammatory bowel, crohn's disease, ulcerative colitis, differential diagnosis

Epidemiology and Pathophysiology
The inflammatory bowel diseases--Crohn's disease (CD) and ulcerative colitis (UC)--are illnesses of unknown cause.