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A-32 Clinical Case Slide - General Medicine I

Medicine & Science in Sports & Exercise: May 2013 - Volume 45 - Issue 5S - p 16–18
doi: 10.1249/01.mss.0000433607.46481.3e

May 29, 2013, 9:30 AM - 11:10 AM

Room: 103

134 Chair: Francis G. O’Connor, FACSM. Uniformed Services University, Bethesda, MD.

(No relationships reported)

135 Discussant: Kenneth Leclerc. San Antonio, TX.

(No relationships reported)

136 Discussant: William O. Roberts, FACSM. University of Minnesota, St Paul, MN.

(No relationships reported)

137 May 29, 9:30 AM - 9:50 AM

Eye Pain in a Volleyball Player

Emily Martin, Aurelia Nattiv, FACSM. University of California Los Angeles, Los Angeles, CA.

(No relationships reported)

HISTORY: 20 year-old division 1 men’s volleyball player presents with right eye pain. During practice, one day prior to presentation, athlete was hit on the right side of his face with a volleyball. He initially noted a dark spot in the right side of his vision, which lasted 5 minutes and completely resolved within 15 minutes. During the rest of the day, he felt normal with no eye pain or vision disturbances. When he woke up the morning of presentation, however, he noted the dark spot in his vision again. It lasted 5 minutes, but resolved on its own and he was feeling well by the time he arrived for evaluation. He does not wear contacts and has no previous history of eye injury. He reports no headache, confusion, balance problems, dizziness, nausea or vomiting. No floaters, flashing lights or blurry vision.


Meds: None

FHx: Non-contributory

ROS: Negative except as noted in HPI


Upon gross examination of the right eye, there is no bruising or swelling around the eye, no scleral injection. Extra-ocular motion intact and pupils equal, round and reactive to light. Non-dilated fundoscopic exam reveals sharp optic discs with normal-appearing blood vessels. Vision is 20/20 bilaterally. No ttp along the orbit.



Commotio Retinae

Retinal Detachment

Corneal Abrasion

Lens Dislocation



Exam by Ophthalmology: Optic disc size is 0.3 bilaterally with normal-appearing nerve fiber, retina, macula and blood vessels bilaterally. There is patchy retinal whitening with scattered intraretinal heme. No retinal hole, tear, detachment or subretinal fluid. Schaffer’s sign negative. Pupils were equal, round and reactive to light, vision 20/20 bilaterally.


Inferior Commotio Retinae OD


1.Strict retinal detachment precautions

2.No contact sports for at least 24 hours

3.Eye protection when returning to sports

4.Returned to sport 48 hours after the injury

5.Follow up with ophthalmology revealed resolving commotio/retinal whitening, no retinal detachment/tear/hole. Negative Schaffer’s sign. There was small residual area of whitening with resolving intra-retinal heme. Pupils round and reactive, 20/20 vision bilaterally. Pressure with applanation 12 OD. Follow up in 1-2 weeks for repeat DFE.

138 May 29, 9:50 AM - 10:10 AM

Progressive Neck Pain In A 24-year-old Male

Gerardo Vazquez, Justin M. Wright. Texas Tech Health Science Center Paul L. Foster School of Medicine, El Paso, TX.

(No relationships reported)

HISTORY: A 24-year-old male presented to the clinic with a 3 month history of thoracic back pain. The pain was located in the posterior right shoulder and radiated from the neck to mid right back. The pain limited his head rotation to the right and when he extended his right shoulder. The shoulder pain was most pronounced at his job as a waiter when he was having increased difficulty carrying plates on the serving tray. Acetaminophen improved the pain. He was diagnosed with right trapezius muscle spasm and treated with cyclobenzaprine 5 mg at night, given a consult for physical therapy, and told to return in 4 weeks if the pain persisted. The patient did not return until 17 months later, complaining of left hand numbness and weakness for the previous 2 months. He noted difficulty playing his guitar and holding objects in his left hand. He also complained of bilateral posterior leg and foot numbness. He denied any loss of power in the legs, or any bowel or bladder incontinence.

PHYSICAL EXAMINATION: After returning to the clinic, musculoskeletal exam revealed weakness with wrist extension bilaterally and normal shoulder abduction strength bilaterally. Patient also had normal balance and toe walk. Neurologic exam revealed hypothenar wasting bilaterally, hyperreflexia, positive Hoffman’s sign and positive Babinski on right. There was no sensory deficit.


1. Trapezius muscle spasm

2. Ulnar Neuropathy

3. Spinal stenosis

4. CNS Neoplasm

5. Thoracic outlet syndrome


MRI of Cervical Spine:

• Intramedullary solid and cystic lesion involving the cervical and upper thoracic cord.

• The lesion is located from C5 through T1-T2 level and extends to the cervicomedullary junction to T6 level caudally. Findings consistent with primary intramedullary neoplasm.


Cervical and thoracic cord ependymoma


1. Patient was admitted to hospital where neurosurgery gave final recommendations to consult MD Anderson Cancer Center in Houston TX.

2. Patient seen at MD Anderson. He was started on high dose oral steroids and scheduled for surgical removal of tumor in November 2012.

3. Currently, the patient has no complaints and will await spinal surgery in November 2012.

139 May 29, 10:10 AM - 10:30 AM

Head Injury - Football

Christopher Robinson, James Clugston, Nicholas Cassisi, Anthony Pass. University of Florida, Gainesville, FL.

(No relationships reported)

HISTORY: Day0: A 23yr old Division I college football lineman presented with Eye Pain and Headache after taking a helmet to helmet hit during which his helmet shifted sideways covering his right eye. Shortly after presenting to the head athletic trainer with these complaints he also had 1 episode of vomiting, he denied any loss of consciousness or difficulties with his vision. He complained of a slight electrical sensation down his right side when the hit originally occurred but no weakness and no continuation of that sensation.

Day2: Continued to have photophobia and eye pain that was worse with eye movements. Denied blurry vision or double vision.

Day3: Right eye swelling, redness and appears to be bulging out, Patient states that his mother first noticed that his eye was bulging out after he had blown his nose forcefully, after that he noticed increased eye pain with eye movement.


Day0: Examination on the sidelines and later in the training room demonstrated no abnormalities specifically in Cranial nerve exam, vestibular exam, or cerebellar testing. He did have alterations from baseline in his Post Concussive Symptoms (PCS) exam, Balance Error Scoring System (BESS) exam, and King Devick Test (KDT).

Day2: Normal PE, Improved PCS, BESS, and KDT. No pain in any bony prominences around right eye, extra-ocular muscles intact, minimal conjunctiva injection.

Day3: Proptosis of right eye, worse conjunctiva injection



2)Intracranial Hemorrhage

3)Corneal Abrasion

4)Skull or Facial Fracture

5)Orbital Fracture


ORBITAL XRAY: 7 views (Day2):

-no fracture seen, no abnormalities

CT SCAN (Day3):

-Diffuse intraconal/preseptal air

-Severe proptosis of right eye - tenting of optic globe and stretching of optic nerve

-Fracture of the right lamina papyracea


-Medial orbital wall blow out

-Tension orbit relieved-More than 50% of intraconal/preseptal air reabsorbed


1)Medial Orbital Wall fracture



1)Neurocognitive and Physical Rest, avoidance of blowing nose

2)Monitor fracture and resolution of intraconal/preseptal air (repeat CT)

3)On Day7: PCS,BESS, KDT, and ImPACT returned to baseline, and on Day8: return to play protocol started, Day11: Returned to competition

140 May 29, 10:30 AM - 10:50 AM

Memory Loss In A 64 Year Old Triathlete

Amy L. Corrigan. Memorial Family Practice Residency, South Bend, IN. (Sponsor: Mark E. Lavallee, FACSM)

(No relationships reported)

Hx: 64 y.o. triathlete noticed changes in his personality and performance for 4- 6 weeks prior to presenting. These changes included slurred speech, left sided facial droop, and difficulty with pronunciation along with memory loss including leaving his triathlon bike at the airport parking lot. Prior to going to the ER, he withdrew from a half ironman, because of an unusual poor cycling performance. He has an extensive travel history due to elite competition both national and abroad. He finally presented to the ER on 4/24/12 with the above complaints. PMHx includes hiatal hernia, clavicle and ulnar/radial fracture. No recent hx of alcohol or tobacco abuse. FMHx pertinent to lymphoma. Px: Afebrile. Vital signs within normal limits. A&O. Mild left sided facial droop and slurred speech. PERRLA and EOMI intact. Oropharynx unremarkable. RRR, no murmurs. CTAB. Abdomen soft, NTND, +BS. Strength 5/5. Reflexes +2.


1. CVA

2. Bell’s palsy

3. Malignant intracerebral mass

4. Multiple sclerosis

5. Cerebral hemorrhage

6. Concussion

7. Cerebritis

8. Coccidioidomycosis

9. Atypical or Ocular Migraines


CT and MRI on 4/24/12 - showed 4.1 × 3.6 cm mass with multiple cystic spaces in the right frontal lobe with edema, mass effect, and midline shift of 1.2 cm to the left, compressing right ventricle suggesting high grade glioblastoma multiforme with necrosis.

CT of chest, abdomen and pelvis and chest x-ray 4/24/12 - unremarkable

Post operative CT brain/ MRI - unremarkable, no bleeding, interval resection

Final Working Dx:

1. Stage IV (T1, M0, G4) glioblastoma multiforme of the right frontal


1. Admitted to the hospital for right frontal lobectomy the next day.

2. Pathology results - Glioblastoma multiforme. Approximately 96% of the tumor was resected. The tumor was negative for P16, MGMT positive in 5% of cells, P53 positive in 5% of cells, P10 positive in greater than 95% of cells and negative for IDHI immunohistochemistry.

3. Postop recovery was uneventful with no signs of deficits. Steroids and Keppra started.

4. Six weeks of radiation along with Temodar during radiation and then Temodar 5 days once a month for two years.

Follow up: Six months later he continues to follow up with his oncologist and is enrolled in the Novocure trial and continues to take Temodar along with Keppra, Protonix and Decadron. Poor prognosis.

141 May 29, 10:50 AM - 11:10 AM

Chest Pain-softball

Laura Fralich1, J. Herbert Stevenson1, Greg Little2. 1University of Massachusetts, Worcester, MA. 2University of Massachusetts, Amherst, MA.

(No relationships reported)

HISTORY: A 19 year old female college freshman softball player presented to the team physician complaining of right upper chest pain for two weeks. She is a right-handed pitcher. Her pain is sharp and occasionally radiates up her right neck. The pain is worse with throwing, moving the right arm, and occasionally with deep breaths. She denies arm weakness, numbness, or tingling.

PHYSICAL EXAM: General-Well-developed, well-nourished female in no acute distress. Neck-supple, no masses. CVS-Regular rate and rhythm, 2+ bilateral upper extremity pulses, capillary refill < 2 seconds. Respiratory-clear to auscultation bilaterally. No increased work of breathing. Musculoskeletal-fit habitus. Tenderness of 2nd and 3rd ribs and intercostal areas in mid-axillary line with palpation. No anterior rib or right clavicle tenderness with palpation. No chest pain with AP compression. Pain in upper right chest with lateral chest compression. No scapular pain. Normal upper extremity strength.


Chest wall muscle strainCostochondritis

Stress fracture of rib


Referred pain from liver and/or gallbladder

Radicular pain from cervical or thoracic spine

Tests and RESULTS:

Xrays (4/8/11, 5/1/12): Negative.

Bone density scan (4/12/11):

Focal increased uptake involving the lateral aspect of 6th or

7th rib as well as right SC joint.

MRI (9/9/11, 2/8/12, 4/18/12): Findings consistent with residua of right

sternal stress fracture at margin of proximal right clavicle; chronic stress

fracture of right proximal clavicle

CT (5/7/12): Irregularity and deformity of articular surface of the right medial clavicle at the SC joint, including an ununited ossific fragment in the superior aspect of the right SC joint. Normal anatomic alignment at the SC and AC joints.

Labs (4/25/12):

Sed rate 7.00 normal Vitamin D 47 normal Magnesium 1.9 normal

H&H 13.3 & 38 normal WBC 5.5 normal MCV 92.5normal

AlkPhos 66 normal Phosphorus 3.3 normal Calcium 9.1 normal TSH 1.86 normal


Stress fracture of 6th or 7th right ribs.

Stress fracture of the right proximal clavicle at SC joint.

SICK scapula.



Physical therapy

Gradual return to play

© 2013 American College of Sports Medicine