An independent medical examination (IME) is a medical evaluation performed by a medical professional on a patient who was not previously involved in the treatment of that patient, to evaluate the patient’s course of prior treatment and current condition. IMEs are conducted by doctors, psychologists, and other licensed healthcare professionals in essentially all medical disciplines, depending on the purpose of the exam and the claimed injuries. Such examinations are generally conducted in the context of a legal or administrative proceeding, at the request of the party opposing the patient’s request for benefits. Conducting an independent medical examination does not establish a typical doctor-patient relationship as exists when a clinician treats a patient. Thus, a “limited doctor-patient relationship” exists when conducting independent medical examinations.

BACKGROUND: Lambert-Eaton myasthenic syndrome is well known to be a classical paraneoplastic syndrome of small cell lung carcinoma (SCLC). Three cases of seronegative myasthenia gravis (MG) and SCLC were previously reported. CASE REPORT: A 65-year-old man developed a severe progressive respiratory failure with clinical features of MG. Tests showed a decremental response in the repetitive nerve stimulation test, abnormal single-fiber electromyography, and positive acetylcholine receptor antibody. SCLC was confirmed by the lung biopsy. CONCLUSIONS: This case represents the first case of seropositive MG and SCLC.
Acetylcholine ; Aged ; Electromyography ; Humans ; Lambert-Eaton Myasthenic Syndrome ; Lung ; Myasthenia Gravis ; Paraneoplastic Syndromes ; Respiratory Insufficiency ; Small Cell Lung Carcinoma

BACKGROUND: The results of the National Institute of Neurological Disorders and Stroke (NINDS) r-tPA Stroke Trial generated considerable hope, but also concerns about whether their results could be replicated in clinical practice. We investigated whether r-tPA infusion could be administered in a community-based hospital, safely and effectively. METHODS: We analyzed, retrospectively, the data of 33 patients having suffered acute ischemic strokes and treated with intravenous r-tPA from February 2003 to December 2006. Safety was evaluated by intracranial hemorrhage, symptomatic intracranial hemorrhage, and mortality. Clinical neurological status was measured by National Institutes of Health Stroke Scale (NIHSS) at baseline, 24 hours, and 7 days after r-tPA treatment. Efficacy was assessed by the response rate of r-tPA using an improvement in the NIHSS by 4 or more points at 24 hours after treatment and the long-term out-come measured with the modified Rankin Scale (mRS) at 3 months after stroke. RESULTS: The median NIHSS was 18. Mean onset to needle time was 140+/-30 minutes. Of the 33 patients, 10 had intracranial hemorrhage and 2 had symptomatic intracranial hemorrhage. No deaths occurred. Fifteen patients showed improvement in their NIHSS by 4 or more points at 24 hours after r-tPA. On the mRS, 12 patients had a good outcome at 3 months. More specifically, 9 patients had no or minimal symptoms, 7 patients had mild to moderate disability, 10 patients had severe disability and 7 patients died. CONCLUSION: The safety andrd efficacy of administering intravenous r-tPA for acute ischemic stroke in a community-based hospital mirror the results of the NINDS stroke trial.
Humans ; Intracranial Hemorrhages ; National Institute of Neurological Disorders and Stroke ; National Institutes of Health (U.S.) ; Needles ; Retrospective Studies ; Stroke ; Tissue Plasminogen Activator

BACKGROUND: The results of the National Institute of Neurological Disorders and Stroke (NINDS) r-tPA Stroke Trial generated considerable hope, but also concerns about whether their results could be replicated in clinical practice. We investigated whether r-tPA infusion could be administered in a community-based hospital, safely and effectively. METHODS: We analyzed, retrospectively, the data of 33 patients having suffered acute ischemic strokes and treated with intravenous r-tPA from February 2003 to December 2006. Safety was evaluated by intracranial hemorrhage, symptomatic intracranial hemorrhage, and mortality. Clinical neurological status was measured by National Institutes of Health Stroke Scale (NIHSS) at baseline, 24 hours, and 7 days after r-tPA treatment. Efficacy was assessed by the response rate of r-tPA using an improvement in the NIHSS by 4 or more points at 24 hours after treatment and the long-term out-come measured with the modified Rankin Scale (mRS) at 3 months after stroke. RESULTS: The median NIHSS was 18. Mean onset to needle time was 140+/-30 minutes. Of the 33 patients, 10 had intracranial hemorrhage and 2 had symptomatic intracranial hemorrhage. No deaths occurred. Fifteen patients showed improvement in their NIHSS by 4 or more points at 24 hours after r-tPA. On the mRS, 12 patients had a good outcome at 3 months. More specifically, 9 patients had no or minimal symptoms, 7 patients had mild to moderate disability, 10 patients had severe disability and 7 patients died. CONCLUSION: The safety andrd efficacy of administering intravenous r-tPA for acute ischemic stroke in a community-based hospital mirror the results of the NINDS stroke trial.
Humans ; Intracranial Hemorrhages ; National Institute of Neurological Disorders and Stroke ; National Institutes of Health (U.S.) ; Needles ; Retrospective Studies ; Stroke ; Tissue Plasminogen Activator

An impairment evaluation by the independent medical examination is requisite for the preparation of reparation, compensation, and welfare. The reparation is defined: 1) something done or given as amends or satisfaction, 2) the payment of damages restoration to good condition, 3) the making of amends for wrong or injury done. Compensation means that something given or received as an equivalent for services, debt, loss, injury, suffering, lack, and others. Welfare is a very popular term in recent modern society. It is a goal of the ministry for health, welfare and family affairs' policies. It means the health, comfort, happiness and general wellbeing of a person or social group. An independent medical examination is possible when a doctor who has not been involved in a patient's care examines the patient. It may be conducted to determine the cause, extent and medical treatment of a work-related injury; whether a worker has reached maximum benefit from treatment; and whether any permanent impairment remains after treatment. Independent medical examinations serve valuable individual and social goals, but participating physicians must appreciate the legal exposure they create. Given the realities of our medical malpractice system, physicians' employment decisions, like patients' treatment decisions, should be adequately informed.
Compensation and Redress ; Employment ; Happiness ; Humans ; Malpractice ; Stress, Psychological

Even a single brain infarct can cause dementia when it occurs in functionally critical areas of the brain. A 71- year-old female developed sudden cognitive impairment without any other focal neurologic deficits. A brain MRI revealed a bilateral anterior fornix infarction. Neuropsychological evaluation revealed verbal and visual memory deficits, visuospatial dysfunction, and frontal executive dysfunction. The cognitive impairment did not improve for 3 months and the patient showed impairments in daily activities. We report a patient who demonstrated strategic infarct dementia after a bilateral anterior fornix infarction.
Brain ; Dementia* ; Dementia, Vascular ; Female ; Fornix, Brain ; Humans ; Infarction* ; Magnetic Resonance Imaging ; Memory Disorders ; Neurologic Manifestations

BACKGROUND: Under certain conditions, exertional headaches may reflect coronary ischemia. CASE REPORT: A 44-year-old woman developed intermittent exercise-induced headaches with chest tightness over a period of 10 months. Cardiac catheterization followed by acetylcholine provocation demonstrated a right coronary artery spasm with chest tightness, headache, and ischemic effect of continuous electrocardiography changes. The patient's headache disappeared following intra-arterial nitroglycerine injection. CONCLUSIONS: A coronary angiogram with provocation study revealed variant angina and cardiac cephalalgia, as per the International Classification of Headache Disorders (code 10.6). We report herein a patient with cardiac cephalalgia that manifested as reversible coronary vasospasm following an acetylcholine provocation test.
Acetylcholine ; Adult ; Angina Pectoris ; Cardiac Catheterization ; Cardiac Catheters ; Coronary Vasospasm ; Coronary Vessels ; Electrocardiography ; Female ; Headache ; Headache Disorders ; Humans ; Ischemia ; Nitroglycerin ; Spasm ; Thorax

Central pontine myelinolysis (CPM) is well-recognized osmotic demyelination syndrome that is related to various conditions such as rapid correction of hyponatremia and chronic alcoholism. Acute ataxia as a sole clinical sign in CPM is rare. We report a case of a 59-year-old man with dysarthria, intention tremor, and a significant gait ataxia starting after alcohol withdrawal, with radiological evidence of CPM. CPM should be included in the differential diagnosis of alcoholic patients who develop a sudden ataxia. Chronic alcohol abuse is one of the most commonly encountered predisposing factors. Alcohol withdrawal represents an additional vulnerability factor, being responsible for electrolyte imbalances which are not always demonstrable but are certainly involved in the development of CPM.
Alcoholics* ; Alcoholism ; Ataxia ; Causality ; Demyelinating Diseases ; Diagnosis, Differential ; Dysarthria ; Gait Ataxia ; Humans ; Hyponatremia ; Middle Aged ; Myelinolysis, Central Pontine* ; Tremor

Hemichorea have been reported in patients with nonketotic hyperglycemia. Usually, hemichorea and hyperglycemia are concomitant. A 73-year-old woman was admitted for investigation of an acute hemichorea. T1-weighted brain magnetic resonance imaging showed hyperintensity in the right putamen. Although she was a diabetic patient, she had no hyperglycemia. Interestingly, 4 weeks earlier, the patient was admitted due to nonketotic hyperglycemia. However, there were no hemichorea at that time. Although pathophysiologically controversial, a delayed hemichorea without nonketotic hyperglycemia should be considered as one of many different causes when evaluating acute hemichorea in diabetic patients.
Aged ; Brain ; Chorea ; Female ; Humans ; Hyperglycemia* ; Magnetic Resonance Imaging ; Putamen

Treatment-induced neuropathy in diabetes (also referred to as insulin neuritis) is considered a rare iatrogenic small fiber neuropathy caused by an abrupt improvement in glycemic control in the setting of chronic hyperglycemia. The prevalence and risk factors are unknown. It presents with neuropathic pain, symptoms of autonomic dysfunction, or a combination of both. We present a case that illustrates the range of presentations of the acute treatment-induced small fiber neuropathy in a patient with diabetes mellitus.
Acute Pain* ; Blood Glucose* ; Diabetes Mellitus ; Diabetic Neuropathies ; Erythromelalgia ; Humans ; Hyperglycemia ; Insulin ; Neuralgia ; Prevalence ; Risk Factors