David Beatty is a 5 year old boy brought to his family doctor by his mother. She is concerned about his clumsiness. He had always been a little 'slow' with his gross-motor milestones. His mother recalled that he did not start walking until he was 20 months old. As he has gotten older, he has seemed less able to keep up with other children his age. As an example she explains that she sees other kindergarten children at the school playground who all seem to be able to run, climb and hop without difficulty. But not David. He is slow, cannot climb well, and falls very often. He also tires out quickly. She worries that maybe he has a problem with the bones in his legs, or maybe a problem with his hips. On examination, David is 111 cm tall (50th percentile), weighs 21 kg (75th percentile), and has a head circumference of 52 cm (75th percentile). He is a happy boy and is eager to tell stories about his teacher and classmates. When standing he has a prominent lordotic curve to his back. He has difficulty climbing up on the examination table, but insists on doing it himself. His heart, lungs and abdomen appear normal. His joints have full range of motion and he does not appear to have any joint or bone pain. His muscle bulk appears to be good - in fact he has large, muscular-looking calves. His deep tendon reflexes are normal (grade 2 out of 4).

David Beatty is a 5 year old boy brought to his family doctor by his mother. She is concerned about his clumsiness. He had always been a little 'slow' with his gross-motor milestones. His mother recalled that he did not start walking until he was 20 months old. As he has gotten older, he has seemed less able to keep up with other children his age. As an example she explains that she sees other kindergarten children at the school playground who all seem to be able to run, climb and hop without difficulty. But not David. He is slow, cannot climb well, and falls very often. He also tires out quickly. She worries that maybe he has a problem with the bones in his legs, or maybe a problem with his hips. On examination, David is 111 cm tall (50th percentile), weighs 21 kg (75th percentile), and has a head circumference of 52 cm (75th percentile). He is a happy boy and is eager to tell stories about his teacher and classmates. When standing he has a prominent lordotic curve to his back. He has difficulty climbing up on the examination table, but insists on doing it himself. His heart, lungs and abdomen appear normal. His joints have full range of motion and he does not appear to have any joint or bone pain. His muscle bulk appears to be good - in fact he has large, muscular-looking calves. His deep tendon reflexes are normal (grade 2 out of 4).

David Beatty is a 5 year old boy brought to his family doctor by his mother. She is concerned about his clumsiness. He had always been a little 'slow' with his gross-motor milestones. His mother recalled that he did not start walking until he was 20 months old. As he has gotten older, he has seemed less able to keep up with other children his age. As an example she explains that she sees other kindergarten children at the school playground who all seem to be able to run, climb and hop without difficulty. But not David. He is slow, cannot climb well, and falls very often. He also tires out quickly. She worries that maybe he has a problem with the bones in his legs, or maybe a problem with his hips. On examination, David is 111 cm tall (50th percentile), weighs 21 kg (75th percentile), and has a head circumference of 52 cm (75th percentile). He is a happy boy and is eager to tell stories about his teacher and classmates. When standing he has a prominent lordotic curve to his back. He has difficulty climbing up on the examination table, but insists on doing it himself. His heart, lungs and abdomen appear normal. His joints have full range of motion and he does not appear to have any joint or bone pain. His muscle bulk appears to be good - in fact he has large, muscular-looking calves. His deep tendon reflexes are normal (grade 2 out of 4).

Carmen Shellinger is a 32-year-old office manager at a local law firm. Her regular office duties include transcription for the senior partner. Over the past few weeks she has noticed pain in the right wrist at the end of the day. On some occasions she has been awakened at night by pain, tingling and numbness in the right hand. After shaking the hand, the symptoms seem to settle down and she has been able to fall asleep. Her symptoms have become more persistent and she decides to seek her doctor's help. Carmen is otherwise healthy and general inquiry identifies only occasional neck and shoulder pain. The results from the neurological examination are normal. Phalen's manoeuvre reproduces her symptoms in the right hand that she has experienced at night. Tinel's sign provokes numbness into the lateral 3 fingers of the right hand.

Ivan is a 68 year old man who has enjoyed excellent health in the past. His only medication is hydrochlorothiazide for mild hypertension. For the past few weeks he noticed that by the end of the day he had difficulty focusing his eyes and keeping them open. He decided to see his family physician when the other day his vision became double. On the day of the visit, Ivan was feeling even worse. His double vision was present shortly after lunch and he felt generally weak. On observation, it was clear that Ivan had a right-sided ptosis. He kept closing one eye and then the other, complaining that otherwise his vision was double. His voice seemed mildly hoarse. Blood pressure was normal at 135/80. General physical examination of the heart, lungs, and abdomen was normal. Neurological examination showed that the pupils were equal and reactive. A prominent ptosis was present on the right. The extra ocular movements were abnormal with dysconjugate gaze present intermittently and not consistently on lateral, upward, and downward gaze. The other cranial nerves were normal. Tone was normal in the limbs. He had some difficulty holding up his arms in the air for more than a couple of minutes. He had some difficulty doing more that 5 deep knee bends. Sensation was normal and the reflexes were all present and symmetric. The plantar responses were down going. You ask Ivan to close his eyes and rest them for a few minutes while you make some notes. You ask him then to open his eyes and temporarily the double vision is much better and the ptosis is almost gone! A referral is made to the neurologist on call. She asks that you send Ivan to the emergency room so that she can perform a tensilon test to confirm the diagnosis.

Carmen Shellinger is a 32-year-old office manager at a local law firm. Her regular office duties include transcription for the senior partner. Over the past few weeks she has noticed pain in the right wrist at the end of the day. On some occasions she has been awakened at night by pain, tingling and numbness in the right hand. After shaking the hand, the symptoms seem to settle down and she has been able to fall asleep. Her symptoms have become more persistent and she decides to seek her doctor's help. Carmen is otherwise healthy and general inquiry identifies only occasional neck and shoulder pain. The results from the neurological examination are normal. Phalen's manoeuvre reproduces her symptoms in the right hand that she has experienced at night. Tinel's sign provokes numbness into the lateral 3 fingers of the right hand.

Remember back in MF1... Ron Chen is a 25 year old computer sciences graduate student who had been previously well. Three weeks ago he suffered a viral gastroenteritis from which he has recovered. Over the past week, he has noticed increasing weakness of his limbs, starting with his legs, and progressing to involve his arms. He reports he has experienced patchy areas of sensory loss, symmetrically (glove and stocking distribution). He has also noticed occasional clumsy speech and facial weakness. He is admitted to the hospital (medical ward) with a diagnosis of Guillain Barré syndrome. You see him in followup 12 months later. After spending 3 weeks in hospital, 4 weeks in a rehabilitation center and then having physiotherapy for the rest of the year, Ron is almost completely back to normal. He still reports some weakness with extension of his toes on the right, but this does not impair his functioning. During his visit, he asks if he will ever get the strength back in his toes, and whether this could happen again

Carmen Shellinger is a 32-year-old office manager at a local law firm. Her regular office duties include transcription for the senior partner. Over the past few weeks she has noticed pain in the right wrist at the end of the day. On some occasions she has been awakened at night by pain, tingling and numbness in the right hand. After shaking the hand, the symptoms seem to settle down and she has been able to fall asleep. Her symptoms have become more persistent and she decides to seek her doctor's help. Carmen is otherwise healthy and general inquiry identifies only occasional neck and shoulder pain. The results from the neurological examination are normal. Phalen's manoeuvre reproduces her symptoms in the right hand that she has experienced at night. Tinel's sign provokes numbness into the lateral 3 fingers of the right hand.

Remember back in MF1... Ron Chen is a 25 year old computer sciences graduate student who had been previously well. Three weeks ago he suffered a viral gastroenteritis from which he has recovered. Over the past week, he has noticed increasing weakness of his limbs, starting with his legs, and progressing to involve his arms. He reports he has experienced patchy areas of sensory loss, symmetrically (glove and stocking distribution). He has also noticed occasional clumsy speech and facial weakness. He is admitted to the hospital (medical ward) with a diagnosis of Guillain Barré syndrome. You see him in followup 12 months later. After spending 3 weeks in hospital, 4 weeks in a rehabilitation center and then having physiotherapy for the rest of the year, Ron is almost completely back to normal. He still reports some weakness with extension of his toes on the right, but this does not impair his functioning. During his visit, he asks if he will ever get the strength back in his toes, and whether this could happen again

Carmen Shellinger is a 32-year-old office manager at a local law firm. Her regular office duties include transcription for the senior partner. Over the past few weeks she has noticed pain in the right wrist at the end of the day. On some occasions she has been awakened at night by pain, tingling and numbness in the right hand. After shaking the hand, the symptoms seem to settle down and she has been able to fall asleep. Her symptoms have become more persistent and she decides to seek her doctor's help. Carmen is otherwise healthy and general inquiry identifies only occasional neck and shoulder pain. The results from the neurological examination are normal. Phalen's manoeuvre reproduces her symptoms in the right hand that she has experienced at night. Tinel's sign provokes numbness into the lateral 3 fingers of the right hand.

Mandy Wallsmith is a 19-year-old young lady who has been brought to the Emergency Department because of problems walking. Approximately one week ago, she noticed some numbness in her left leg. She thought she had slept on it the wrong way initially, but then the numbness persisted. The next day she fell while skating and landed on her backside. Over the next few days, she reports feeling significant pain in her lower back and progressive “heaviness” in her left leg. She began having difficulty lifting her left leg. She also noticed that her right leg seemed to feel cold when she showered. After speaking to her parents about her symptoms, she was brought to a walk-in clinic where an x-ray of the spine was ordered. This reported no fractures, and Mandy was advised to follow-up with her family doctor if her symptoms did not improve in the next few days. When she started to have episodes of urinary incontinence, her parents became very concerned, and decided to bring her to the Emergency Department.

Mandy Wallsmith is a 19-year-old young lady who has been brought to the Emergency Department because of problems walking. Approximately one week ago, she noticed some numbness in her left leg. She thought she had slept on it the wrong way initially, but then the numbness persisted. The next day she fell while skating and landed on her backside. Over the next few days, she reports feeling significant pain in her lower back and progressive “heaviness” in her left leg. She began having difficulty lifting her left leg. She also noticed that her right leg seemed to feel cold when she showered. After speaking to her parents about her symptoms, she was brought to a walk-in clinic where an x-ray of the spine was ordered. This reported no fractures, and Mandy was advised to follow-up with her family doctor if her symptoms did not improve in the next few days. When she started to have episodes of urinary incontinence, her parents became very concerned, and decided to bring her to the Emergency Department.

Mandy Wallsmith is a 19-year-old young lady who has been brought to the Emergency Department because of problems walking. Approximately one week ago, she noticed some numbness in her left leg. She thought she had slept on it the wrong way initially, but then the numbness persisted. The next day she fell while skating and landed on her backside. Over the next few days, she reports feeling significant pain in her lower back and progressive “heaviness” in her left leg. She began having difficulty lifting her left leg. She also noticed that her right leg seemed to feel cold when she showered. After speaking to her parents about her symptoms, she was brought to a walk-in clinic where an x-ray of the spine was ordered. This reported no fractures, and Mandy was advised to follow-up with her family doctor if her symptoms did not improve in the next few days. When she started to have episodes of urinary incontinence, her parents became very concerned, and decided to bring her to the Emergency Department.

Six months after her previous presentation of transverse myelitis, from which she completely recovered, Mandy Wallsmith returns with complaints of bilateral visual loss (worse on the right). The problem started two days ago with pain in and behind her right eye, worse when she would look to the left or right. Yesterday, she began to notice that she wasn't seeing well out of her right eye. Today her vision seems worse, although the pain is a little better. On examination, her visual acuity is found to be 20/80 in the left eye (OS) and 20/400 in the right eye (OD). Visual field appears to be normal in the left eye, but she can only detect hand motion (not finger counting) in all quadrants with the right eye. She finds that colours look less vivid with her right eye - especially red, which looks "kind of gray".

Six months after her previous presentation of transverse myelitis, from which she completely recovered, Mandy Wallsmith returns with complaints of bilateral visual loss (worse on the right). The problem started two days ago with pain in and behind her right eye, worse when she would look to the left or right. Yesterday, she began to notice that she wasn't seeing well out of her right eye. Today her vision seems worse, although the pain is a little better. On examination, her visual acuity is found to be 20/80 in the left eye (OS) and 20/400 in the right eye (OD). Visual field appears to be normal in the left eye, but she can only detect hand motion (not finger counting) in all quadrants with the right eye. She finds that colours look less vivid with her right eye - especially red, which looks "kind of gray".

Six months after her previous presentation of transverse myelitis, from which she completely recovered, Mandy Wallsmith returns with complaints of bilateral visual loss (worse on the right). The problem started two days ago with pain in and behind her right eye, worse when she would look to the left or right. Yesterday, she began to notice that she wasn't seeing well out of her right eye. Today her vision seems worse, although the pain is a little better. On examination, her visual acuity is found to be 20/80 in the left eye (OS) and 20/400 in the right eye (OD). Visual field appears to be normal in the left eye, but she can only detect hand motion (not finger counting) in all quadrants with the right eye. She finds that colours look less vivid with her right eye - especially red, which looks "kind of gray".

Neil Wartson is a 4-year-old boy who is being seen by his family doctor for right-sided hearing loss. According to his mother, his hearing was fine at birth (based on the initial screening tests performed), but seems to have slowly worsened on the left over time. He began complaining of “ringing” in his right ear approximately 6 months ago. It was initially intermittent, but seems to have become more constant over time. He is also reported to have difficulty responding when spoken to on the right side. He is otherwise well and developmentally normal. There is a family history of bilateral hearing impairment in Neil’s father. This has not previously been investigated. On examination, Neil is found to have reduced hearing to whispered words on the right. Rinne and Weber’s tests support sensorineural hearing loss on the right. The family doctor orders formal audiology testing and a sedated MRI. She also suggests that it might be helpful for Neil’s father to be assessed for his hearing loss.

Neil Wartson is a 4-year-old boy who is being seen by his family doctor for right-sided hearing loss. According to his mother, his hearing was fine at birth (based on the initial screening tests performed), but seems to have slowly worsened on the left over time. He began complaining of “ringing” in his right ear approximately 6 months ago. It was initially intermittent, but seems to have become more constant over time. He is also reported to have difficulty responding when spoken to on the right side. He is otherwise well and developmentally normal. There is a family history of bilateral hearing impairment in Neil’s father. This has not previously been investigated. On examination, Neil is found to have reduced hearing to whispered words on the right. Rinne and Weber’s tests support sensorineural hearing loss on the right. The family doctor orders formal audiology testing and a sedated MRI. She also suggests that it might be helpful for Neil’s father to be assessed for his hearing loss.

Neil Wartson is brought back to his family doctor 6 months later. The MRI has still not been performed, but the audiology testing confirmed severe sensorineural hearing loss on the right. Upon entering the office, Neil’s mother is very upset and agitated. Over the last month, she has noticed that Neil has become clumsier and is falling frequently. He also has started to rub his eye a lot and complains that things are “fuzzy”. She also reports that, since the last visit, Neil’s father has been investigated for his hearing loss. He is currently being worked up for Neurofibromatosis Type II. Neil’s mother has looked this up on the internet and is convinced that Neil has this as well.

Neil Wartson is brought back to his family doctor 6 months later. The MRI has still not been performed, but the audiology testing confirmed severe sensorineural hearing loss on the right. Upon entering the office, Neil’s mother is very upset and agitated. Over the last month, she has noticed that Neil has become clumsier and is falling frequently. He also has started to rub his eye a lot and complains that things are “fuzzy”. She also reports that, since the last visit, Neil’s father has been investigated for his hearing loss. He is currently being worked up for Neurofibromatosis Type II. Neil’s mother has looked this up on the internet and is convinced that Neil has this as well.

Shelley Clerke is a 72-year-old woman who has had Parkinson's disease for over 10 years. Initially the disorder presented with tremor on her right side. She has been managed by her family doctor and local neurologist. Over the years her medications have been adjusted and new medications added to control her symptoms. More recently, she is experiencing increasing difficulty with activities such as eating and signing her name due to the tremor. Two years ago she started using a rollator walker when her balance and overall mobility made it difficult for her to ambulate in the community with just a cane. Today she has an appointment with her neurologist. The neurologist notes the increase in tremor and her poor overall mobility compared to when he last reviewed her 6 months ago. Her Parkinson medications include: Levodopa/carbidopa 250/25 mg QID, entacapone 200 mg QID, ropinirole 3 mg QID, and amantidine 100 mg BID. On examination she has an obvious and severe right-sided resting tremor that does not completely stop when she raises her arms. She has difficulty getting out of the chair and on to the examination table.

Shelley Clerke is a 72-year-old woman who has had Parkinson's disease for over 10 years. Initially the disorder presented with tremor on her right side. She has been managed by her family doctor and local neurologist. Over the years her medications have been adjusted and new medications added to control her symptoms. More recently, she is experiencing increasing difficulty with activities such as eating and signing her name due to the tremor. Two years ago she started using a rollator walker when her balance and overall mobility made it difficult for her to ambulate in the community with just a cane. Today she has an appointment with her neurologist. The neurologist notes the increase in tremor and her poor overall mobility compared to when he last reviewed her 6 months ago. Her Parkinson medications include: Levodopa/carbidopa 250/25 mg QID, entacapone 200 mg QID, ropinirole 3 mg QID, and amantidine 100 mg BID. On examination she has an obvious and severe right-sided resting tremor that does not completely stop when she raises her arms. She has difficulty getting out of the chair and on to the examination table.

Shelley Clerke is a 72-year-old woman who has had Parkinson's disease for over 10 years. Initially the disorder presented with tremor on her right side. She has been managed by her family doctor and local neurologist. Over the years her medications have been adjusted and new medications added to control her symptoms. More recently, she is experiencing increasing difficulty with activities such as eating and signing her name due to the tremor. Two years ago she started using a rollator walker when her balance and overall mobility made it difficult for her to ambulate in the community with just a cane. Today she has an appointment with her neurologist. The neurologist notes the increase in tremor and her poor overall mobility compared to when he last reviewed her 6 months ago. Her Parkinson medications include: Levodopa/carbidopa 250/25 mg QID, entacapone 200 mg QID, ropinirole 3 mg QID, and amantidine 100 mg BID. On examination she has an obvious and severe right-sided resting tremor that does not completely stop when she raises her arms. She has difficulty getting out of the chair and on to the examination table.

Shelley Clerke is a 72-year-old woman who has had Parkinson's disease for over 10 years. Initially the disorder presented with tremor on her right side. She has been managed by her family doctor and local neurologist. Over the years her medications have been adjusted and new medications added to control her symptoms. More recently, she is experiencing increasing difficulty with activities such as eating and signing her name due to the tremor. Two years ago she started using a rollator walker when her balance and overall mobility made it difficult for her to ambulate in the community with just a cane. Today she has an appointment with her neurologist. The neurologist notes the increase in tremor and her poor overall mobility compared to when he last reviewed her 6 months ago. Her Parkinson medications include: Levodopa/carbidopa 250/25 mg QID, entacapone 200 mg QID, ropinirole 3 mg QID, and amantidine 100 mg BID. On examination she has an obvious and severe right-sided resting tremor that does not completely stop when she raises her arms. She has difficulty getting out of the chair and on to the examination table.

Shelley Clerke is a 72-year-old woman who has had Parkinson's disease for over 10 years. Initially the disorder presented with tremor on her right side. She has been managed by her family doctor and local neurologist. Over the years her medications have been adjusted and new medications added to control her symptoms. More recently, she is experiencing increasing difficulty with activities such as eating and signing her name due to the tremor. Two years ago she started using a rollator walker when her balance and overall mobility made it difficult for her to ambulate in the community with just a cane. Today she has an appointment with her neurologist. The neurologist notes the increase in tremor and her poor overall mobility compared to when he last reviewed her 6 months ago. Her Parkinson medications include: Levodopa/carbidopa 250/25 mg QID, entacapone 200 mg QID, ropinirole 3 mg QID, and amantidine 100 mg BID. On examination she has an obvious and severe right-sided resting tremor that does not completely stop when she raises her arms. She has difficulty getting out of the chair and on to the examination table.

Emily Slott is a 10-year-old girl who has been brought to the Emergency Department with a new onset of seizures. Emily is reported by her parents to have been previously healthy and developmentally normal. She began complaining of headache and fatigue yesterday. She was given some acetaminophen and went to bed. When her mother checked on her, she had an oral temperature of 39.9°C. She was very sleepy, but took more acetaminophen. This morning, when her mother was going past Emily’s room, she heard some unusual thumping and gurgling noises. When she entered the room, she found Emily laying in bed “stiff as a board”, “frothing at the mouth”, with “her whole body shaking” and “her eyes rolled back in her head”. From when her mother found her, the event lasted an additional 2-3 minutes. After the shaking stopped, Emily became limp and unresponsive. She was still febrile. EMS was called and Emily was brought to the hospital.

Emily Slott is a 10-year-old girl who has been brought to the Emergency Department with a new onset of seizures. Emily is reported by her parents to have been previously healthy and developmentally normal. She began complaining of headache and fatigue yesterday. She was given some acetaminophen and went to bed. When her mother checked on her, she had an oral temperature of 39.9°C. She was very sleepy, but took more acetaminophen. This morning, when her mother was going past Emily’s room, she heard some unusual thumping and gurgling noises. When she entered the room, she found Emily laying in bed “stiff as a board”, “frothing at the mouth”, with “her whole body shaking” and “her eyes rolled back in her head”. From when her mother found her, the event lasted an additional 2-3 minutes. After the shaking stopped, Emily became limp and unresponsive. She was still febrile. EMS was called and Emily was brought to the hospital.

Emily Slott is a 10-year-old girl who has been brought to the Emergency Department with a new onset of seizures. Emily is reported by her parents to have been previously healthy and developmentally normal. She began complaining of headache and fatigue yesterday. She was given some acetaminophen and went to bed. When her mother checked on her, she had an oral temperature of 39.9°C. She was very sleepy, but took more acetaminophen. This morning, when her mother was going past Emily’s room, she heard some unusual thumping and gurgling noises. When she entered the room, she found Emily laying in bed “stiff as a board”, “frothing at the mouth”, with “her whole body shaking” and “her eyes rolled back in her head”. From when her mother found her, the event lasted an additional 2-3 minutes. After the shaking stopped, Emily became limp and unresponsive. She was still febrile. EMS was called and Emily was brought to the hospital.

Emily Slott is a 10-year-old girl who has been brought to the Emergency Department with a new onset of seizures. Emily is reported by her parents to have been previously healthy and developmentally normal. She began complaining of headache and fatigue yesterday. She was given some acetaminophen and went to bed. When her mother checked on her, she had an oral temperature of 39.9°C. She was very sleepy, but took more acetaminophen. This morning, when her mother was going past Emily’s room, she heard some unusual thumping and gurgling noises. When she entered the room, she found Emily laying in bed “stiff as a board”, “frothing at the mouth”, with “her whole body shaking” and “her eyes rolled back in her head”. From when her mother found her, the event lasted an additional 2-3 minutes. After the shaking stopped, Emily became limp and unresponsive. She was still febrile. EMS was called and Emily was brought to the hospital.

Emily Slott is a 10-year-old girl who has been brought to the Emergency Department with a new onset of seizures. Emily is reported by her parents to have been previously healthy and developmentally normal. She began complaining of headache and fatigue yesterday. She was given some acetaminophen and went to bed. When her mother checked on her, she had an oral temperature of 39.9°C. She was very sleepy, but took more acetaminophen. This morning, when her mother was going past Emily’s room, she heard some unusual thumping and gurgling noises. When she entered the room, she found Emily laying in bed “stiff as a board”, “frothing at the mouth”, with “her whole body shaking” and “her eyes rolled back in her head”. From when her mother found her, the event lasted an additional 2-3 minutes. After the shaking stopped, Emily became limp and unresponsive. She was still febrile. EMS was called and Emily was brought to the hospital.

Emily Slott is a 10-year-old girl who has been brought to the Emergency Department with a new onset of seizures. Emily is reported by her parents to have been previously healthy and developmentally normal. She began complaining of headache and fatigue yesterday. She was given some acetaminophen and went to bed. When her mother checked on her, she had an oral temperature of 39.9°C. She was very sleepy, but took more acetaminophen. This morning, when her mother was going past Emily’s room, she heard some unusual thumping and gurgling noises. When she entered the room, she found Emily laying in bed “stiff as a board”, “frothing at the mouth”, with “her whole body shaking” and “her eyes rolled back in her head”. From when her mother found her, the event lasted an additional 2-3 minutes. After the shaking stopped, Emily became limp and unresponsive. She was still febrile. EMS was called and Emily was brought to the hospital.

Emily Slott is a 10-year-old girl who has been brought to the Emergency Department with a new onset of seizures. Emily is reported by her parents to have been previously healthy and developmentally normal. She began complaining of headache and fatigue yesterday. She was given some acetaminophen and went to bed. When her mother checked on her, she had an oral temperature of 39.9°C. She was very sleepy, but took more acetaminophen. This morning, when her mother was going past Emily’s room, she heard some unusual thumping and gurgling noises. When she entered the room, she found Emily laying in bed “stiff as a board”, “frothing at the mouth”, with “her whole body shaking” and “her eyes rolled back in her head”. From when her mother found her, the event lasted an additional 2-3 minutes. After the shaking stopped, Emily became limp and unresponsive. She was still febrile. EMS was called and Emily was brought to the hospital.

Andrea, an 84-year-old woman, is accompanied by her niece to her family physician's office. Andrea has been living on her own ever since her husband died 10 years ago. Her niece Bev would occasionally pick up some groceries for her aunt. Andrea was always proud to be independent. As she got older, Bev noted that her aunt was a bit forgetful, but put that down to simply getting older. Last month her aunt's neighbour called Bev to tell her that her aunt's hydro was disconnected. Bev was surprised. Her aunt hadn't called her that there was any trouble. Bev noted that her aunt hadn't really called her much over the last few months. Bev went over to her aunt's house. Her aunt greeted her at the door. Her aunt was surprised to see her, even though Bev had called her that day to tell her that she was coming to visit. Bev was surprised to see that her aunt had lost a fair amount of weight. She was even more surprised about the unkempt nature of her aunt's house. This was a woman who prided herself on organization and cleanliness. After much discussion and arguing, Andrea agreed to see her family physician for a routine checkup. She hadn't been to the doctor's for some time.

Emily Slott is a 10-year-old girl who has been brought to the Emergency Department with a new onset of seizures. Emily is reported by her parents to have been previously healthy and developmentally normal. She began complaining of headache and fatigue yesterday. She was given some acetaminophen and went to bed. When her mother checked on her, she had an oral temperature of 39.9°C. She was very sleepy, but took more acetaminophen. This morning, when her mother was going past Emily’s room, she heard some unusual thumping and gurgling noises. When she entered the room, she found Emily laying in bed “stiff as a board”, “frothing at the mouth”, with “her whole body shaking” and “her eyes rolled back in her head”. From when her mother found her, the event lasted an additional 2-3 minutes. After the shaking stopped, Emily became limp and unresponsive. She was still febrile. EMS was called and Emily was brought to the hospital.

Brenda Farnett, an 82-year-old right-handed woman, was reviewed in the stroke prevention clinic for a possible TIA. Her past medical history included hypertension, treated hypothyroidism, and diet-controlled type II diabetes. Her medications included ASA, HCTZ, and eltroxin. She was initially referred from her family physician's office for evaluation of an episode of right-sided weakness and numbness, mostly involving the arm, lasting about 15 minutes. Her examination in the clinic showed her to be mildly hypertensive at 150/90, and with a regular pulse at 76. Her neurological examination was normal. Her EKG done that day was normal (sinus rhythm). An urgent carotid ultrasound was arranged and she was started on clopidogrel 75 mg OD, ramipril 2.5 mg OD, and atorvastatin 10 mg OD. On the following morning she awoke with mild right-sided weakness and an inability to speak. Her husband immediately called 911. She was taken to the nearest hospital.

Brenda Farnett, an 82-year-old right-handed woman, was reviewed in the stroke prevention clinic for a possible TIA. Her past medical history included hypertension, treated hypothyroidism, and diet-controlled type II diabetes. Her medications included ASA, HCTZ, and eltroxin. She was initially referred from her family physician's office for evaluation of an episode of right-sided weakness and numbness, mostly involving the arm, lasting about 15 minutes. Her examination in the clinic showed her to be mildly hypertensive at 150/90, and with a regular pulse at 76. Her neurological examination was normal. Her EKG done that day was normal (sinus rhythm). An urgent carotid ultrasound was arranged and she was started on clopidogrel 75 mg OD, ramipril 2.5 mg OD, and atorvastatin 10 mg OD. On the following morning she awoke with mild right-sided weakness and an inability to speak. Her husband immediately called 911. She was taken to the nearest hospital.

Andrea, an 84-year-old woman, is accompanied by her niece to her family physician's office. Andrea has been living on her own ever since her husband died 10 years ago. Her niece Bev would occasionally pick up some groceries for her aunt. Andrea was always proud to be independent. As she got older, Bev noted that her aunt was a bit forgetful, but put that down to simply getting older. Last month her aunt's neighbour called Bev to tell her that her aunt's hydro was disconnected. Bev was surprised. Her aunt hadn't called her that there was any trouble. Bev noted that her aunt hadn't really called her much over the last few months. Bev went over to her aunt's house. Her aunt greeted her at the door. Her aunt was surprised to see her, even though Bev had called her that day to tell her that she was coming to visit. Bev was surprised to see that her aunt had lost a fair amount of weight. She was even more surprised about the unkempt nature of her aunt's house. This was a woman who prided herself on organization and cleanliness. After much discussion and arguing, Andrea agreed to see her family physician for a routine checkup. She hadn't been to the doctor's for some time.

Brenda Farnett, an 82-year-old right-handed woman, was reviewed in the stroke prevention clinic for a possible TIA. Her past medical history included hypertension, treated hypothyroidism, and diet-controlled type II diabetes. Her medications included ASA, HCTZ, and eltroxin. She was initially referred from her family physician's office for evaluation of an episode of right-sided weakness and numbness, mostly involving the arm, lasting about 15 minutes. Her examination in the clinic showed her to be mildly hypertensive at 150/90, and with a regular pulse at 76. Her neurological examination was normal. Her EKG done that day was normal (sinus rhythm). An urgent carotid ultrasound was arranged and she was started on clopidogrel 75 mg OD, ramipril 2.5 mg OD, and atorvastatin 10 mg OD. On the following morning she awoke with mild right-sided weakness and an inability to speak. Her husband immediately called 911. She was taken to the nearest hospital.

Brenda Farnett, an 82-year-old right-handed woman, was reviewed in the stroke prevention clinic for a possible TIA. Her past medical history included hypertension, treated hypothyroidism, and diet-controlled type II diabetes. Her medications included ASA, HCTZ, and eltroxin. She was initially referred from her family physician's office for evaluation of an episode of right-sided weakness and numbness, mostly involving the arm, lasting about 15 minutes. Her examination in the clinic showed her to be mildly hypertensive at 150/90, and with a regular pulse at 76. Her neurological examination was normal. Her EKG done that day was normal (sinus rhythm). An urgent carotid ultrasound was arranged and she was started on clopidogrel 75 mg OD, ramipril 2.5 mg OD, and atorvastatin 10 mg OD. On the following morning she awoke with mild right-sided weakness and an inability to speak. Her husband immediately called 911. She was taken to the nearest hospital.

Brenda Farnett, an 82-year-old right-handed woman, was reviewed in the stroke prevention clinic for a possible TIA. Her past medical history included hypertension, treated hypothyroidism, and diet-controlled type II diabetes. Her medications included ASA, HCTZ, and eltroxin. She was initially referred from her family physician's office for evaluation of an episode of right-sided weakness and numbness, mostly involving the arm, lasting about 15 minutes. Her examination in the clinic showed her to be mildly hypertensive at 150/90, and with a regular pulse at 76. Her neurological examination was normal. Her EKG done that day was normal (sinus rhythm). An urgent carotid ultrasound was arranged and she was started on clopidogrel 75 mg OD, ramipril 2.5 mg OD, and atorvastatin 10 mg OD. On the following morning she awoke with mild right-sided weakness and an inability to speak. Her husband immediately called 911. She was taken to the nearest hospital.

Petter Khant, a 6-year-old boy, is brought to his family doctor by his mother because of concerns that he is not learning in school. He is described as a "high energy child", always on the go. He has a very short attention span. His teacher sent along a note explaining that Petter is well behind the expectations for this age. His classmates are learning the sounds that go with different letters, but Petter does not yet even have a concept of letters or numbers. His vocabulary seems very limited, both receptive and expressive. His mother recalls no concerns about his early development. She remembers him as a generally healthy baby. He started to crawl at 9 months and could walk on his own by 13 months. He only began to use a few single words at 2 years of age. A hearing test done at that time was normal.

Petter Khant, a 6-year-old boy, is brought to his family doctor by his mother because of concerns that he is not learning in school. He is described as a "high energy child", always on the go. He has a very short attention span. His teacher sent along a note explaining that Petter is well behind the expectations for this age. His classmates are learning the sounds that go with different letters, but Petter does not yet even have a concept of letters or numbers. His vocabulary seems very limited, both receptive and expressive. His mother recalls no concerns about his early development. She remembers him as a generally healthy baby. He started to crawl at 9 months and could walk on his own by 13 months. He only began to use a few single words at 2 years of age. A hearing test done at that time was normal.

Petter Khant, a 6-year-old boy, is brought to his family doctor by his mother because of concerns that he is not learning in school. He is described as a "high energy child", always on the go. He has a very short attention span. His teacher sent along a note explaining that Petter is well behind the expectations for this age. His classmates are learning the sounds that go with different letters, but Petter does not yet even have a concept of letters or numbers. His vocabulary seems very limited, both receptive and expressive. His mother recalls no concerns about his early development. She remembers him as a generally healthy baby. He started to crawl at 9 months and could walk on his own by 13 months. He only began to use a few single words at 2 years of age. A hearing test done at that time was normal.