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Case 2: Patent foramen ovale (PFO) and paradoxical embolism
  1. Roby D Rakhit
  1. Hammersmith Hospital, London, UK

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A 36 year old woman ruptured her right Achilles tendon in a skiing accident. Previous medical history is unremarkable except for a history of migraine for many years. She is married with three children with no history of spontaneous miscarriage. She smokes 15 cigarettes a day and takes the oral contraceptive pill.

She is admitted to a local hospital where surgery to repair the Achilles tendon is performed followed by fitting of a plaster cast. Due to pain from the plaster cast she is slow to mobilise. On day 7 postoperatively she develops increasing pain in the right leg. When the plaster is removed the right calf is found to be painful, warm, and swollen. The next day while straining on the toilet she collapsed with left arm weakness. Clinical examination revealed dysarthria with pyramidal weakness of the left arm.

The significance of these symptoms, the diagnosis, and the short and long term treatment of these postoperative problems are discussed in an interactive case presentation.

Learning objectives

When you have completed this case you should understand:

  1. The importance of screening for thrombophilia in a patient with unexplained thromboembolism

  2. The association between PFO, atrial septal aneurysm and cryptogenic stroke

  3. The clinical diagnosis of PFO

  4. The clinical syndromes associated with PFO

  5. Controversies in the management of patients with PFO and cryptogenic stroke: medical versus surgical versus percutaneous device closure.


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