A 26-year-old Malaysian woman (childbearing age) attended a private primary care clinic with a known case of gastroesophageal reflux disease (GERD) and complained of persistent nausea and a few episodes of vomiting. She had no known drug allergy, no surgical history, no hospitalization in the last two years, was a non-smoker, and no history of drug or alcohol abuse. The patient was prescribed Tab metoclopramide 10 mg TDS and Tab ranitidine 150 mg BD for five days. About 30 min after oral administration of both medicines, her eyes rolled involuntary upward, leading to lateral deviation of the eyes, and mouth jaws clenched as if “dislocated jaws.” The patient was immediately brought into an emergency department (ED) of a public tertiary care hospital. A drug challenge test was done which resulted in the withdrawal of metoclopramide. The accompanied sister later disclosed that the patient had taken metoclopramide and ranitidine from a private clinic earlier in the day. The patient self-assumed to have a sudden seizure, due to excessive hot weather and dehydration. A slow intravenous infusion of 50 mg/mL diphenhydramine hydrochloride in 0.9% w/v NaCl 100 mL was administered stat. Consequently, the symptoms vanished after approximately 30 min of the therapy, devoid of relapse. The patient was discharged from ED post 8 hours of monitoring with complete recovery. Physicians frequently prescribe metoclopramide to treat nausea and vomiting, which may cause adverse drug reaction of acute dystonic oculogyric crisis (OGC). Due to its unwanted and unpredictable extrapyramidal symptoms, metoclopramide should be prescribed and dispensed with caution. Thorough history taking at ED is imperative for correct early diagnosis and treatment, as metoclopramide-induced dystonic OGC has a high probability of confusion with other causes of dystonia such as conversion and seizures, encephalitis, tetanus, and hypercalcemic tetany.

Ingrown toe nail is one of the commonest foot lesion affecting young individuals. The recurrence rate with a variety of treatment modalities continues to be quite significant. Hence the need to develop a comprehensive combination therapy to reduce the recurrence rate. Onychocryptosis or ingrown toe nail is a common and painful form of nail disease. It affects adolescents and young males very commonly. A combination therapy comprising of wedge resection of the nail, matricectomy, phenol cauterization and wedge excision of hyper granulations for recurrent advanced presentation of ingrown toe nail is presented.  A 32-year-old male with a history of recurrent ingrown toe nail, operated twice previously presented with an advanced stage of ingrown toe nail. Hypertrophic granulation tissue covered both lateral and medial nail plates. The patient was treated with an integrated surgical approach comprising of wedge resection of medial as well as lateral border of nail ensuring removal of spicules on either side, followed by wedge resection of underlying nail bed. This was followed by phenol cauterization and elliptical excision of hypertrophic granulations. The predisposing factors, natural history and treatment modalities are discussed. Combination therapy is a safe and the best option for recurrent ingrown toe nail. It can also be used as a form of primary treatment in fresh cases to prevent recurrence.

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Hirayama"s disease is a rare benign neurological disorder. It is also referred to as Monomelic amyotrophy and Juvenile muscular atrophy of distal upper extremities. This disease was first described by Hirayama et al. in 1959. The disease is usually focal lower motor neuron type of disease and due its benign nature it can be distinguished from other lower motor neuron disorders like Amyotrophic Lateral Sclerosis (ALS). It is most commonly seen in Asian countries like India and Japan affecting young males usually in the second or third decades. Pathogenesis of the disease is debated. Dynamic spinal cord compression due to neck flexion with forward displacement of posterior dura is considered as the primary mechanism. The cause of the disease is unknown in majority of the people. We report a case of Hirayama"s disease having unilateral involvement of the right upper extremity and describe the clinical features & the MR Imaging findings along with the mechanism behind its characteristic appearance. CASE REPORT 18 year male came with complaints of weakness in his right hand and difficulty in gripping and holding objects since 1 year. Onset was insidious in nature and gradually progressed from difficulty in gripping objects to inability to unbutton the shirt with the right hand. There was no associated pain or loss of sensation. He had also noticed ABSTRACT Hirayama"s disease is a rare benign neurological disorder also known as monomelic amyotrophy, Sobue disease, Juvenile Muscular Atrophy of Distal Upper Extremity (JMADUE). It mainly affects young males in their second or third decades and is most commonly seen in Asian countries like Japan, Malaysia and India. In majority of the cases the cause of the disease is unknown. An 18 year male came with weakness in his right hand and forearm since 1 year. Examination revealed weakness and wasting of muscles of forearm and hand without lower limb involvement and normal deep tendon reflexes. MRI showed focal short segment hyperintense signal in the ventral and right lateral aspect of the cervical cord at C5-C6 level with the involved segment measuring 4x3mm in size. Based on clinical and radiological features a diagnosis of focal amyotrophy was made. Patient is given a cervical collar to prevent flexion at the neck and physiotherapy in the form of hand and forearm exercises were started. Regular follow up of the patient once every 2 months is being done. Hirayama"s disease is a rare, benign, self-limiting neurological disorder. Early diagnosis and management by preventing cervical flexion with the help of a cervical collar has shown to halt the progression of the disease.

Thoracic Outlet Syndrome (TOS) refers to a constellation of signs and symptoms that arise from compression of the neurovascular bundle within the confined space of the thoracic outlet. Neurogenic (nTOS) from brachial plexus compression (95%), venous (vTOS) from subclavian vein compression (3%), & arterial (aTOS) from subclavian artery compression (1%). Most common clinical presentation of aTOS patients is distal upper extremity arterial emboli in otherwise healthy patient. Presenting a case report of arterial thoracic outlet syndrome.