An elderly man presented with severe right ear pain and discharge, hoarseness and dysphagia causing significant involuntary weight loss. Extensive investigations by varied specialties only highlighted right vocal cord palsy and right parotid lymphadenitis. Reassessment on transfer to a rehabilitation ward noted clinically subtle right Ramsay Hunt syndrome with multiple lower cranial nerve involvement. We illustrate a case of varicella zoster virus cranial polyneuritis with bulbar symptoms mimicking bulbar stroke, requiring percutaneous endoscopic gastrostomy feeds, with significant clinical and radiological recovery over 1 year.

SUMMARYA 61-year-old man presented to a country clinic with involuntary orofacial movements and progressive cognitive decline, causing significant disability and psychosocial distress. Review of records uncovered a 7-year history of presentations to several specialties, including memory clinics, neurology, internal medicine and emergency departments, with varied symptoms, extensive complex work up and inconclusive diagnosis. Comprehensive review at our hospital highlighted inconsistent neurological signs, fluctuating cognition and psychosocial stressors, which preceded symptom onset, leading to the diagnosis of a functional movement disorder (FMD), which subsequently improved with relaxation therapy, cognitive-behavioural therapy and physiotherapy. We illustrate a variety of somatic symptoms, diagnostic clues and management outcomes for FMDs, and the importance of diagnostic criteria to minimise costly, time-consuming and ultimately unnecessary tests of exclusion. BACKGROUND

Background: In clinical practice, achieving 4 weeks of therapeutic anticoagulation with warfarin is challenging and hinders timely DCCV. Dabigatran is a safe and effective alternative. We evaluated the difference in time to DCCV and success rate between those on dabigatran compared to warfarin. Method: Patients who had DCCV between 12/1/2011 and 31/12/2013 were prospectively collected. Patient demographics and electronic clinical documentations were retrospectively reviewed. Results: Total of 168 DCCV were performed on 153 patients. Mean age was 61 years and mean BMI was 32kg/m 2 with male predominance (80.4%). 87.6% of patients were referred from Cardiology and 12.4% from General Medicine. 45.2% (n = 76) were on dabigatran. The median days to DCCV with dabigatran was 63 days (IQR = 44-100 days) and 86 days for warfarin (IQR = 56-121days), p < 0.05. The overall immediate success rate of DCCV was 80.4%. 94.1% of atrial flutter (AFL) had successful cardioversion and 76.5% for atrial fibrillation (AF). At median follow-up of 108 days, 25.5% remained in sinus rhythm (SR). Those with AFL, 50% (n = 17) remained in SR at median follow up of 69 days while 18.5% of AF remained in SR at median follow up of 130.5 days. There was no difference in the immediate success of DCCV between dabigatran and warfarin groups (80.3% vs 80.4%, p = 0.89). AF accounted for 80.3% and 77.2% respectively. Conclusion: The median time to outpatient DCCV was 23 days shorter with dabigatran compared warfarin therapy. There was no difference in success rate between the 2 anticoagulation groups.