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Telehealth utilizes information technologies and communication networks to deliver healthcare and education with lower costs and improved access, quality, and efficiency of healthcare services.  This report describes the application of telehealth for medical screening, clinical decision making, and medical referral in a physical therapy practice. The patient described was a 50-year old man who contacted his physical therapist via telephone for a chief complaint of worsening left sided numbness and tingling that began insidiously 2 days prior.  Further questioning revealed that the patient also complained of left ankle weakness, and slight unsteadiness with walking. He had not been feeling well and had been experiencing increasing bouts of unexplained fatigue over the previous two months that were now interfering with his work and recreational activities. The patient was evaluated by his physician the next day.  Magnetic resonance imaging of the brain revealed a large (4 cm) falcine meningioma in the right parietal region.  The patient was immediately referred to a neurosurgeon and underwent a craniotomy and tumor resection ten days later and subsequent gamma knife radiosurgery of the residual tumor bed two months after craniotomy and tumor resection.  Follow-up imaging one year later revealed no evidence of recurrence or residual tumor.  This patient case underscores the importance of recognizing signs and symptoms of serious disease, and how referral following telehealth via telephone can inform diagnosis.

PURPOSEThe purpose of this report is to describe the diagnostic focus of the clinical decision-making process for a patient referred to a physiotherapist for treatment of persistent dizziness, who was subsequently diagnosed with severe stenosis of the internal carotid arteries. CASE DESCRIPTIONThe patient was a 79-year-old man who was referred to a physiotherapist by his primary care physician for the treatment of persistent intermittent dizziness. The patient’s dizziness began 6 months prior insidiously; it was worsening over time and now interfered with activities of daily living. The patient denied cervical pain or headaches, numbness or tingling in his extremities, difficulty maintaining balance with walking, unsteadiness, muscle weakness, dysphagia, drop attacks, diplopia or dysarthria. At the physiotherapist’s initial evaluation, cervical range of motion was moderately restricted in all motions and his dizziness was elicited with changes in head position. The patient’s neurological examination was unremarkable. Due to positional complaints of dizziness, a Dix–Hallpike test was used to screen for benign paroxysmal positional vertigo, which was positive for symptoms reproduction; however, no nystagmus was noted. The patient also became diaphoretic and exhibited significant discoloration of his face during the test. OUTCOMESDue to concern over vascular compromise, carotid duplex ultrasonography and magnetic resonance angiography were completed and revealed near complete occlusion of the left internal carotid artery at its origin. The patient subsequently underwent a left internal carotid endarterectomy with resolution of symptoms and a return to all activities of daily living. DISCUSSIONCarotid artery stenosis, although frequently asymptomatic until severe, may manifest as complaints of dizziness that mimic peripheral vestibular dysfunction. Appropriate and prudent screening and referral is necessary if clinical symptoms suggestive of vascular compromise are present.

Introduction: Ultrasonography allows high-resolution visualisation of the peripheral nerves for quantitative and qualitative analyses. We report cross-sectional area values (quantitative measure) and echo intensity values (qualitative measure) for 46 peripheral nerve sites in upper and lower extremities in cadaveric specimens. Objective: To determine cross-sectional area values and echo intensity values of peripheral nerves of upper and lower extremities at 46 nerve sites. Methods: Nerve measurements were obtained using electronic callipers and ultrasonography for linear dimension and cross-sectional area measurements, respectively, in six cadaveric specimens for 46 peripheral nerve sites. Ultrasound images were further analysed to estimate echo intensity percentage values for 46 nerves. Results: We present normal cross-sectional area values of various nerves of upper and lower extremities with their respective echo intensity values. Calculated cross-sectional area values from linear dimensions did not match the measured cross-sectional area values via trace method. Conclusion: Cross-sectional area values (quantitative measure) and echo intensity values (qualitative measure) for 46 peripheral nerve sites in upper and lower extremities in cadaveric specimens are presented. The estimation of cross-sectional area via linear measurement is not a good approximation of the cross-sectional area (cross-sectional area measured by trace method on ultrasound image).

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