Learning on the Web. Case 2: patent foramen ovale (PFO) and paradoxical embolism.

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.