Nitrous oxide is used medically as an anesthetic agent; in the food industry as a propellant for condiments; and recreationally for its euphoric and dissociative effects. We report three cases of nitrous oxide misuse causing severe, symptomatic cobalamin (vitamin B12) deficiency in which signs of nitrous oxide use per se, as well as signs of toxicity, were observed, including characteristic palmar calluses over the metacarpal heads, and frostbite. These signs may assist clinicians in the recognition of nitrous oxide use and the timely diagnosis of nitrous oxide toxicity.

A 49-year-old woman with a complicated hernia presentation, including direct and indirect inguinal hernias, Spigelian hernias, and Pantaloon hernias, is presented in the case report. The diagnosis was verified by a comprehensive physical examination and imaging, which resulted in a Lichtenstein operation for repair. The surgical procedure for hernia comprised of painstaking dissection, reduction of the hernia sac, and implantation of a prosthetic mesh. The instance emphasizes the value of individualized treatment programs and draws attention to the intricate anatomical details of hernia surgery. Analyzing situations that are similar to one another highlights the necessity of customized strategies to improve patient outcomes.

BACKGROUND: Neurofeedback (NF) therapy is brain training using operant conditioning including real-time displays of brain activity to teach people how to regulate their brain function. We would like to present a treatment for a patient who experienced severe traumatic events on 7/10 including physical injury accompanied by difficulty sleeping for two months, nightmares, intrusive thoughts, difficulties in emotional regulation and difficulty in concentrating. Due to the complexity and difficulties in emotional regulation accompanied by severe sleep disturbances, it was decided to treat with medication in combination with neurofeedback. After several training sessions in addition to pharmaceutical treatment, significant relaxation was observed, there was an improvement in concentration and the patient was able to return to his work and normal social functioning. In addition, intrusive thoughts decreased in intensity and frequency.

METHODS: A 29-year-old woman was referred for US of bilateral breasts during evaluation for noncyclical mastalgia predominantly in the left breast of 8 months duration. She had been taking selective serotonin receptor inhibitors for the past 6 months for a clinical diagnosis of generalized anxiety disorder. A detailed medical history revealed breast cancer in the patient\'s mother and grandmother. There was no history of weight loss or appetite loss, nor was there a history of any altered bowel or bladder habits. The patient was overweight, with a body mass index of 26.8 kg/m2, and appeared anxious during the general physical examination, with an increased pulse (102 beats per minute) and normal blood pressure (118/82 mm Hg). Local examination revealed multiple small mobile painful lesions that were palpable in all quadrants of the bilateral breasts, anterior abdominal wall, and forearm. On further questioning, the patient reported similar painful lesions were present in her mother and one brother. Laboratory investigations showed a normal hemoglobin level (12.4 g/dL; normal range, 12-15 g/dL), a total leukocyte count of 9000 cells per microliter (9 cells × 109/L) (normal range, 4500-11 000 cells per microliter [4.5-11 cells × 109/L]), a normal differential leukocyte count (74% neutrophils [normal range, 40%-80%], 24% lymphocytes [normal range, 20%-40%], and 2% eosinophils [normal range, 1%-4%]), and an erythrocyte sedimentation rate of 5 mm per hour (normal range, 0-29 mm per hour). High-frequency US of bilateral breasts (Figs 1, 2) was performed in conjunction with Color Doppler US (Fig 3) and shear-wave elastography of representative lesions in the breasts (Fig 4). Similar lesions were also found in the subcutaneous plane of the right forearm (Fig 5) and the anterior abdominal wall (Fig 6).

An atrial septal defect (ASD) may be detected later in life due to its asymptomatic status. We report a case of superior sinus venosus ASD, a rare type of ASD, in which bedside physical examination was useful for the diagnosis. A 72-year-old male was referred to cardiology during the treatment of a cerebral infarction. On examination, a right ventricular heave, a split-second heart sound with an increased pulmonary component, and a systolic ejection murmur in the pulmonary region were noted. Transthoracic echocardiography showed a systolic pulmonary artery pressure of 50 mmHg with right heart enlargement, but there was no shunt flow. Because an agitated saline contrast study was positive, transesophageal echocardiography was performed and demonstrated direct flow between the left atrium and superior vena cava. Our report highlights the importance of considering ASD, such as sinus venosus type, even in the absence of transthoracic echocardiographic findings suggestive of this condition, when patients present with a bedside physical examination consistent with ASD.

Proptosis is a frequent presenting symptom/sign of many paediatric malignancies. Acute-onset proptosis is an ophthalmic emergency that can endanger vision if not treated promptly. Appropriate treatment must be instituted only after investigating for the underlying aetiology. Here, we report a developmentally delayed boy in middle childhood who presented with recent onset bilateral proptosis. Clinical examination followed by radiological evaluation suggested scurvy to be the underlying cause and vitamin C supplementation led to prompt reversal of proptosis. The relevant literature has been reviewed and presented here to apprise the paediatric oncologists about this rare but easily treatable cause of proptosis.

OBJECTIVE: The aims of this study were to assess the psychological, functional, and physical differences between patients with femoroacetabular impingement (FAI) syndrome and individuals who were asymptomatic (controls) to analyze clinical differences among 4 subtypes of FAI (cam type, cam type with labral tear, pincer type, and pincer type with labral tear), to calculate the correlations among the variables described, and to identify risk factors contributing to the hip function variance.
METHODS: A case-control study was conducted at a hospital rehabilitation unit with a cohort of individuals who were asymptomatic (controls) and a cohort of patients with FAI. Sociodemographic characteristics, pain intensity, psychological health status, hip range of motion (RoM), hip isometric strength, and hip function were assessed.
RESULTS: A total of 69 controls and 69 patients with FAI were analyzed. Although sociodemographic characteristics were comparable between samples, poorer hip RoM, strength, and psychological health were found for the cases. FAI subtypes showed no significant pain intensity, psychological health, or RoM differences (except for hip adduction), but hip strength differed among FAI subtypes. Multiple significant correlations between psychological health, pain intensity, RoM, strength, and hip function were found. The variance values of the International Hip Outcome Tool, Hip Outcome Score (HOS) for daily living activities, and HOS for sports activities were partially explained (47.6%, 36.0%, and 21.6%, respectively) on the basis of kinesiophobia, hip strength, self-efficacy, and anxiety.
CONCLUSIONS: Patients with FAI showed poorer psychological health, hip RoM, and strength than individuals who were asymptomatic and had similar sociodemographic characteristics. FAI subtype influenced the patients\' clinical presentations. Hip strength, kinesiophobia, anxiety, and self-efficacy should be targeted for improving hip function, as they have been demonstrated to be important contributors to hip disability.
CONCLUSIONS: This study demonstrated that pain catastrophizing, hip strength, and hip adduction differed among FAI subtypes. However, hip function and pain intensity were comparable between FAI subtypes.

BACKGROUND: Mesenteric cysts have been typically described as cystic lesions of mesentery or omentum occurring either intra-abdominally or in the retroperitoneum. With no typical symptoms, the preoperative diagnosis of mesenteric cyst becomes challenging to establish.
METHODS: In this case report, we describe the case of a 29-year-old female who presented with abdominal distension for seven years associated with intermittent constipation. Following complete history, a meticulous physical examination was performed. Laboratory investigations and radiological imaging techniques were used to facilitate the diagnosis which was confirmed on laparotomy.
RESULTS: Physical examination revealed abdominal ascites. Laboratory investigations were unremarkable. Abdominal ultrasound revealed multiloculated massive ascites. A well-defined cystic area 27 × 18cm displacing abdominal viscera was observed on computed tomography (abdomen and pelvis) with contrast medium. Exploratory laparotomy revealed a massive cyst involving almost the entire peritoneal cavity. On histopathology, no signs of malignancy were reported. The post-operative course was excellent, and the patient was discharged following surgery.
CONCLUSIONS: As this lesion is rarely considered preoperatively, and the clinical manifestations can be non-specific, we report this case of mesenteric cyst mimicking ascites in order to inform improved decision making among healthcare professionals regarding the timely diagnosis and appropriate management.

METHODS: A 69-year-old right-handed man with a history of substance use disorder, hypertension, and diabetes presented to the emergency department in an unresponsive state. Upon examination, apart from tachycardia (heart rate, 108 beats per minute), vital signs were within normal ranges (blood pressure, 134/102 mm Hg; temperature, 97.9°F [36.6°C]; respiratory rate, 16 breaths per minute; oxygen saturation, 96%). He had a Glasgow coma scale score of 8. Otherwise, the physical examination revealed no abnormalities. His prior psychiatric and surgical histories were unremarkable. There was no history of recent travel, camping, hiking, or vaccination. No family history could be obtained. Laboratory work-up revealed an elevated creatine kinase level (49 006 U/L [818.4 μkat/L]; normal reference range, 10-205 U/L [0.17-3.42 μkat/L]). An electrocardiogram showed sinus tachycardia without evidence of cardiac ischemia. An echocardiogram was unremarkable. Alanine aminotransferase (126 U/L [2.10 μkat/L]; normal reference range, 0-40 U/L [0-0.67 μkat/L]) and aspartate aminotransferase (488 U/L [8.15 μkat/L]; normal reference range, 3-44 U/L [0.05-0.74 μkat/L]) levels were elevated. Polymerase chain reaction results were negative for HIV-1, HIV-2, syphilis treponemal, and COVID-19 antibodies. The rest of the routine laboratory work-up findings were within normal limits. Urine drug screening was positive for cocaine, marijuana, fentanyl, and benzodiazepines. Naloxone was administered, but the patient remained unresponsive. Intubation was performed for airway protection. Noncontrast and contrast-enhanced CT of the head (Fig 1) and CT angiography were performed in the emergency department to rule out an acute intracranial abnormality. Multisequence MRI of the brain with administration of intravenous contrast material was ordered for further assessment (Figs 2-4). CT of the abdomen and pelvis was unremarkable (images not shown).

Subclavian artery stenosis is a relatively uncommon manifestation of peripheral artery disease with significant morbidity. We describe a case of left subclavian artery stenosis that became apparent in the intraoperative setting, in a patient who presented for emergency surgery after a fall and subsequent left femoral neck fracture. Initial non-invasive blood pressure readings on the left upper extremity were in the normal range but after placement of the arterial line on the right upper extremity, the discrepancy was evident pointing towards a structural abnormality as the causative factor. CT angiography was found to confirm the diagnosis of left subclavian artery stenosis of an atherosclerotic nature. A thorough physical examination can point to the presence of subclavian stenosis through pulse amplitude and blood pressure asymmetries. This study highlights the importance of obtaining blood pressure readings ideally on all four limbs to avoid misinterpretation of blood pressure values that could ultimately lead to the use of unnecessary and inadequate interventions and possible complications in the perioperative setting.