Cool case: quick one

[neglect]

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Who can get this?

Elderly patient with multiple medical problems including moderate PD, change in mental status. Afeb, vitals stable. She is completly masked, muttering to herself, follows only simple commands, does not look anywhere except straight ahead, moves all extremities equally. This is a huge change per family. Head CT is normal.

 

[neurodoc]

Who can get this?

Elderly patient with multiple medical problems including moderate PD, change in mental status. Afeb, vitals stable. She is completly masked, muttering to herself, follows only simple commands, does not look anywhere except straight ahead, moves all extremities equally. This is a huge change per family. Head CT is normal.

Could be lots of things. Need more info: How old; Rx history; What medical problems, exactly; etc? Rule out acute metabolic abnormalities. Start with a basic chem panel and CBC. All normal? Response to Rx with anti-Parkinsonian meds? Rule out occult infection: CXR/urinalysis. Pulse oximetry, blood gases? EEG (rule out petit mal status, non-convulsive status)? If still mystified, consider LP.

Nick

 

[Nerdoscience]

What is the question? Do you already know she has PD? Are you just asking why the sudden worsening and altered mental status?

 

[neglect]

Could be lots of things. Need more info: How old; Rx history; What medical problems, exactly; etc? Rule out acute metabolic abnormalities. Start with a basic chem panel and CBC. All normal? Response to Rx with anti-Parkinsonian meds? Rule out occult infection: CXR/urinalysis. Pulse oximetry, blood gases? EEG (rule out petit mal status, non-convulsive status)? If still mystified, consider LP.

Nick

All normal, EEG not done. Next day normal - moderate well controlled PD. What was the intervention?

 

[neurodoc]

All normal, EEG not done. Next day normal - moderate well controlled PD. What was the intervention?

I don't know. She seems to have had an exacerbation of her PD. Let me make a few guesses at the "intervention." You stopped her Reglan, which she was given for nausea? Or you stopped her antipsychotic RX, which she was given for some behavioral problem? Or you gave her some Sinemet? Or...WEll, you get the point.

Nick

 

[Nerdoscience]

I don't understand these vague cases. It's not like this points to anything in particular. Are we just discussing things that can acutely exacerbate Parkinsonism in someone with a known diagnosis of PD? Neurodoc gives common examples of meds that have antidopaminergic effects that could cause that. But the case is so vague, guessing what you are getting at is kind of pointless.

I would also add:
1. You didn't tell us she has a DBS which malfunctioned, and you were able to fix it.
2. She was faking it for attention

 

[neglect]

Thiamine.

The fact that things were vague is exactly correct. I gave you all the relevant information, which is more than you're likely to get in the middle of the night when a patient gets dropped off by her family or by the assisted living place where she lives.

Anybody have any other cases?

 

[Nerdoscience]

So, what you are saying is that her looking straight ahead is really that her eyes are fixed, not that she has attentional problems or that her head doesn't move. And the masked facies isn't new, but park of her PD? Regardless of how little info you get, you can still figure that much out by examining the pt. We didn't have that luxury.

 

[neglect]

So, what you are saying is that her looking straight ahead is really that her eyes are fixed, not that she has attentional problems or that her head doesn't move. And the masked facies isn't new, but park of her PD? Regardless of how little info you get, you can still figure that much out by examining the pt. We didn't have that luxury.

"does not look anywhere except straight ahead"

Have any others?

 

[neurodoc]

"does not look anywhere except straight ahead"

Have any others?

What Nerdoscience and I were saying is that the case was vaguely presented. The fixed mid-position gaze could be part of an exacerbation of PD as well as other things, such as opthalmoplegia. Bediside exam will help clarify what's causing it (supranuclear or infranuclear). Of course anyone presenting to the ER with confusion and oculomotor abnormalities will be suspect for Wernicke's encephalopathy and be given, as a matter of standard ER protocol, the usual banana bag cocktail. Where I work, the EMTs often administer this while the patient is en route to the ER. You didn't mention whether the patient was dysmetric or ataxic, but of course her PD rigidity and bradykinesia might have masked that.

Nick

 

[neglect]

What Nerdoscience and I were saying is that the case was vaguely presented. The fixed mid-position gaze could be part of an exacerbation of PD as well as other things, such as opthalmoplegia. Bediside exam will help clarify what's causing it (supranuclear or infranuclear). Of course anyone presenting to the ER with confusion and oculomotor abnormalities will be suspect for Wernicke's encephalopathy and be given, as a matter of standard ER protocol, the usual banana bag cocktail. Where I work, the EMTs often administer this while the patient is en route to the ER. You didn't mention whether the patient was dysmetric or ataxic, but of course her PD rigidity and bradykinesia might have masked that.

Nick

Exactly. Things are vague in real life. Things get masked. History is often false or misleading. Sometimes we get presented with the subactue onset of, let's say, diplopia and fatiguing dysarthria in a 20 yo woman and no-one can figure it out and things go well. Sometimes not.

Assuming that everyone gets thiamine is a dangerous assumption. The ER is so busy that I trust them to do hemodynamic stability, airways, EKGs, and omni head CTs, not much else. That obviously wasn't the case here.

Speaking of dysarthria, reminds me of a fair one, not as good though. Want a go? Or have a case?

 

[Nerdoscience]

Actually, I like the idea of this thread. The thing is that your presentation was much more vague than a 5 minute Neuro exam. That's all.

 

[danielmd06]

Let's hear more cases!

 

[neglect]

Let's hear more cases!

Easy one:

33 yo male surgery resident presents with numbness in the legs over 3 weeks that was patchy, came and went, eventually came and stayed. Could not urinate. No back pain. In ER his post void was 400 ccs. He had reflexes. Do we need to know anything else? Rx and Tx?

 

[neurodoc]

Easy one:

33 yo male surgery resident presents with numbness in the legs over 3 weeks that was patchy, came and went, eventually came and stayed. Could not urinate. No back pain. In ER his post void was 400 ccs. He had reflexes. Do we need to know anything else? Rx and Tx?

1) What were his reflexes, exactly (give them to us on a 0-4 scale (0=absent, 4=sustained clonus)? Give us his upper and lower extremity reflexes, give us his plantar responses, and give us the umbilical and cremasteric responses. And while you're at it, give us your assesntment of his anal spincter tone.

2) Presumably you tested the strength in his lower and upper extremity muscles. Tell us which ones, if any, were weak, and just how weak were they?

3) What did sensory exam show? Was there a segmental loss of pinprick sensation anywhere? Saddle anesthesia? Was there loss of vibratory sense in the lower extremities?

4) Was your patient ataxic or dysmetric? Did he have nystagmus or an INO?

These are the sorts of questions I would ask an ER doc who called me in the middle of the night to present a case like this.

Nick

 

[Nerdoscience]

Or, if you're the poor Neuro consult resident, would be figuring out yourself before making the diagnosis. Heh, reminds me of this case I had once. The ER said that they had an MS patient with exacerbation. Symptoms were ataxia and dysarthria. Turns out the guy did have MS, and had some interesting old CN VI lesion, and some other stuff. But the symptoms they called about were rapidly resolving. And when I leaned in to do the CN exam, I caught a whiff of booze on his breath.

 

[neurodoc]

neglect,

Just to comment on my last post, the important thing is to "localize" the lesion. Anatomic diagnosis is what clinical neurology is all about. You need to be able to correlate your patient's symptoms and signs to potential lesions of the patient's nervous system. This is a lot like what an electronics expert does when "troubleshooting" a circuit. In order to be able to troubleshoot the nervous system you need to: 1) know the circuitry, i.e. how it is connected and how it works; and 2) be able to test the circuitry, i.e. to observe its functions and correlate these observations to the clinical presentation.

Nick

 

[neglect]

Dude, you need not tell me about clinical localization. We do our best. I gave you the information needed. He has reflexes. I don't need to tell you what red herrings the exam can throw at us. If this guy had none in the legs, then sure, we'd be talking about a different ball park. Or we'd be talking about the same localization with spinal shock.

None of that information is important when you get a stat MRI of spine and find...

Enhancing intra-axial lesion at T4. No rectal required. So to make a long story short, the guy goes on to have a clean brain MRI, inflammatory CSF, steroids with stabilization, and some neuropathic pain.

Any other cases?

 

[PainDr]

Dude, you need not tell me about clinical localization. We do our best. I gave you the information needed. He has reflexes. I don't need to tell you what red herrings the exam can throw at us. If this guy had none in the legs, then sure, we'd be talking about a different ball park. Or we'd be talking about the same localization with spinal shock.

None of that information is important when you get a stat MRI of spine and find...

Dude, someone does need to tell you about clinical localization. If you want to present a case, present it properly...you sound like a 3rd yr student.🙄

If you think POTENTIAL "red herrings" aren't important, you're in for a few surprises. Just wait for the oral boards. Those examiners will chew you up!

 

[neglect]

Dude, someone does need to tell you about clinical localization. If you want to present a case, present it properly...you sound like a 3rd yr student.🙄

If you think POTENTIAL "red herrings" aren't important, you're in for a few surprises. Just wait for the oral boards. Those examiners will chew you up!

Yeah, actually they weren't that hard. They had no to few comments. Thanks for your concern anyway. Look, if you can't get the cases, then don't play, but don't try for even a second to cast doubt on my mad neuro skilz.

 

[PainDr]

Yeah, actually they weren't that hard. They had no to few comments. Thanks for your concern anyway. Look, if you can't get the cases, then don't play, but don't try for even a second to cast doubt on my mad neuro skilz.

Nice comeback but you still sound like a 3rd year.

 

[Nerdoscience]

Okay, honestly, how is it fun if you don't get the whole exam? It's like diagnosing lung cancer from being told they are having trouble keeping their eyes open. Come ON... Can't you get it? She has a Pancoast tumor. It's ptosis. DUH.

 

[neglect]

Okay, honestly, how is it fun if you don't get the whole exam? It's like diagnosing lung cancer from being told they are having trouble keeping their eyes open. Come ON... Can't you get it? She has a Pancoast tumor. It's ptosis. DUH.

If you can't get within 90% certainty of (at least) localization by the time you start the exam, then either you're in trouble or the patient is functional. Neuro is the most fun prior to the answer.

Am I the only one throwing down cases?

Woman with bad RA tries to get off plane, notices she's stiff and numb all over and has new onset dysarthria. I know, it's too obvious.

 

[danielmd06]

Woman with bad RA tries to get off plane, notices she's stiff and numb all over and has new onset dysarthria. I know, it's too obvious.

How old is she? What do CSF and neuroimaging studies show? Physical exam?

My hypothesis is multiple sclerosis.

 

[Nerdoscience]

Oh, it says tries to get off plane. She must be too fat to fit through the door! Maybe she's pregnant with quintuplets! Maybe it's an amniotic fluid embolus to her brain!

No, no wait. It says all over. Maybe she exploded. That MUST be her problem.

 

[Nerdoscience]

Maybe you're going for subluxation of the C spine up near the first two joints causing hypoglossal palsy and cord injury. Maybe she has lupus, and was misdiagnosed with RA, and now she has cerebritis. Maybe she's functional. Honestly, it's so vague. Maybe she did explode.

 

[Nerdoscience]

Actually, could you GIVE an exam for once? Before you blurt out what the answer is? If you haven't noticed, that's all we're asking for.

 

[neglect]

Actually, could you GIVE an exam for once? Before you blurt out what the answer is? If you haven't noticed, that's all we're asking for.

Really, the problem with the exam is that it simply gives away the answer - the history already did. Normal MS. Normal CN but tongue atrophy, spastic all four, between 5- and 4 in body. Patchy sensoy loss below face. Reflexes brisk all 4, toes up. Easy case for neurology.

Actually, it is funny that someone mentioned oral boards. The cases they give you are not complete. You are expected to go off an incomplete exams and, I suppose, mention the missing data, what you would think given the missing data going one way or another. But they're doing away with it anyway, so who cares...

 

[neurodoc]

Really, the problem with the exam is that it simply gives away the answer - the history already did. Normal MS. Normal CN but tongue atrophy, spastic all four, between 5- and 4 in body. Patchy sensoy loss below face. Reflexes brisk all 4, toes up. Easy case for neurology.

Actually, it is funny that someone mentioned oral boards. The cases they give you are not complete. You are expected to go off an incomplete exams and, I suppose, mention the missing data, what you would think given the missing data going one way or another. But they're doing away with it anyway, so who cares...

I'm not sure from your recent posts, but I suspect you are flaming. I don't know whether you are good at bedside exam and neurodiagnosis, but nerdo is right in saying that you are presenting cases too vaguely and to top that off, you are reluctant to answer specific questions about the exam (like the ones I asked in my 9/26 post). In your subsequent comments you lament that "the problem with the exam is that it simply gives away the answer." Well, DUH...

Where are you in your medical training? Have you passed your neuro boards? I passed my board exams ten years ago, and I just recertified. The examiners for my oral exam presented patients just like yours, and I also had to examine a "real" patient (mine had MS). For the several "hypothetical" patients, the examiners sometimes presented very sketchy initial information, as you did on you last case. My response was to ask further questions, as I did for your case. My examiners provided the answers and I went on to give them my diagnoses and recommendations for management. If you really want to make your case presentations realistic and educational, why don't you emulate the ABPN examiners and respond in a helpful way to legitimate questions, such as the ones I asked in my 9/26 post?

I don't want to suggest that you're less interested in honest discussion and education than in showing off what you believe is your neurodiagnostic brilliance. There are many people who post here who have plenty of clinical knowledge and experience, and who are probably at least as brilliant as you are. 🙂

Nick

 

[neglect]

I'm not sure from your recent posts, but I suspect you are flaming. I don't know whether you are good at bedside exam and neurodiagnosis, but nerdo is right in saying that you are presenting cases too vaguely and to top that off, you are reluctant to answer specific questions about the exam (like the ones I asked in my 9/26 post). In your subsequent comments you lament that "the problem with the exam is that it simply gives away the answer." Well, DUH...

Where are you in your medical training? Have you passed your neuro boards? I passed my board exams ten years ago, and I just recertified. The examiners for my oral exam presented patients just like yours, and I also had to examine a "real" patient (mine had MS). For the several "hypothetical" patients, the examiners sometimes presented very sketchy initial information, as you did on you last case. My response was to ask further questions, as I did for your case. My examiners provided the answers and I went on to give them my diagnoses and recommendations for management. If you really want to make your case presentations realistic and educational, why don't you emulate the ABPN examiners and respond in a helpful way to legitimate questions, such as the ones I asked in my 9/26 post?

I don't want to suggest that you're less interested in honest discussion and education than in showing off what you believe is your neurodiagnostic brilliance. There are many people who post here who have plenty of clinical knowledge and experience, and who are probably at least as brilliant as you are. 🙂

Nick

I have no clue if you have a point or not. Obviously everyone has different styles. Some cases all you need is the photo, some need extensive tests.

Instead of writing the above, why don't you post some cases? The purpose of my first post was to share a quick and cool case where neurology made a difference. I thought that it would at very least prompt others to share similar cases. You obviously did not get the point, and instead post this nonsense above. My goal is not to show off "neurodiagnostic brilliance" on a forum where no-one knows my name and, to make my own ad hom, only a freak would believe that to be the case. Yes, I get it, you don't approve of a short case approach. Your approval, however, is of no concern to me. Nor is your opinion. Nor is your (no doubt) pedantic approach.

However, I will tell you that in this format I can think of no other way to keep cases interesting. You pretty much have to hide some of the information or make the cases too obscure to matter. None of the cases have been guess which dysmyelinating syndrome this is. F/A/L acute hemiplegia: interesting? No. Difficult? No. Routine: yes. If you don't like it, then don't play. Or go to Baylor, they have a site you'd like. Neurology is full of simple cases that require almost no mental effort: syncope, most migraines, encephalopathy, CTS. You're a classic critic: bitter attacks, but offering no alternatives of your own. Again, why don't you post some cases?

Neurologists are not the fleas of medicine. We should aim to be able to make subway diagnoses in strangers.

 

[Nerdoscience]

Hemiplegia? What does that have to do with what you described? So, anyway, I think it would be fair if you gave the original info, and then added as it was asked. Then, you could have the thrill of seeing how quickly people can guess the right answer, and we could get off your case. More fun for everyone.

 

[Nerdoscience]

You're a classic critic: bitter attacks, but offering no alternatives of your own.

Um, I think what we were suggesting all along WERE alternatives.

 

[neurodoc]

I have no clue if you have a point or not. Obviously everyone has different styles. Some cases all you need is the photo, some need extensive tests.

Instead of writing the above, why don't you post some cases? The purpose of my first post was to share a quick and cool case where neurology made a difference. I thought that it would at very least prompt others to share similar cases. You obviously did not get the point, and instead post this nonsense above. My goal is not to show off "neurodiagnostic brilliance" on a forum where no-one knows my name and, to make my own ad hom, only a freak would believe that to be the case. Yes, I get it, you don't approve of a short case approach. Your approval, however, is of no concern to me. Nor is your opinion. Nor is your (no doubt) pedantic approach.

However, I will tell you that in this format I can think of no other way to keep cases interesting. You pretty much have to hide some of the information or make the cases too obscure to matter. None of the cases have been guess which dysmyelinating syndrome this is. F/A/L acute hemiplegia: interesting? No. Difficult? No. Routine: yes. If you don't like it, then don't play. Or go to Baylor, they have a site you'd like. Neurology is full of simple cases that require almost no mental effort: syncope, most migraines, encephalopathy, CTS. You're a classic critic: bitter attacks, but offering no alternatives of your own. Again, why don't you post some cases?

Neurologists are not the fleas of medicine. We should aim to be able to make subway diagnoses in strangers.

Neglect,

I don't know why you're getting so worked up over my "criticism" of the vague way you present your cases. We all have "different styles" of neurodiagnosis, but we all follow the "neurologic method" of diagnosis, which is to "localize the lesion" based on the clinical examination (i.e. to answer the question "Where is the lesion?"), and to try to answer the question, "What is the lesion?"

I gathered from your very sketchy presentation that the lesion was probably in the thoracic or lower cervical spinal cord, and I asked you to answer questions about exam findings that would help the bedside clinician localize the lesion to the cord. Instead of answering my questions, you chose to lambast me for asking them. Sure, you could just order an MRI of the entire neuroaxis (brain to sacrum) and find that thoracic lesion, but if that's all there is to it, who needs a neurologist? Let's just order whole body scans, EMGs, EEGs, LPs, and every other possible high-tech lab or imaging study on all patients who present with neurologic symptoms. I guess if expense were no object, we could practice that sort of medicine. I think that would be a chicken**** approach, and would bust the healthcare budget.

I'm trying very hard not to view your responses as those of an ignorant, immature, and arrogant narcissist, but you are making it difficult. Ignorance, immaturity, arrogance, and narcissism are dangerous qualities in a physician. Please don't take these comments "the wrong way." 🙂

Nick

 

[neglect]

Neglect,

I don't know why you're getting so worked up over my "criticism" of the vague way you present your cases. We all have "different styles" of neurodiagnosis, but we all follow the "neurologic method" of diagnosis, which is to "localize the lesion" based on the clinical examination (i.e. to answer the question "Where is the lesion?"), and to try to answer the question, "What is the lesion?"

I gathered from your very sketchy presentation that the lesion was probably in the thoracic or lower cervical spinal cord, and I asked you to answer questions about exam findings that would help the bedside clinician localize the lesion to the cord. Instead of answering my questions, you chose to lambast me for asking them. Sure, you could just order an MRI of the entire neuroaxis (brain to sacrum) and find that thoracic lesion, but if that's all there is to it, who needs a neurologist? Let's just order whole body scans, EMGs, EEGs, LPs, and every other possible high-tech lab or imaging study on all patients who present with neurologic symptoms. I guess if expense were no object, we could practice that sort of medicine. I think that would be a chicken**** approach, and would bust the healthcare budget.

I'm trying very hard not to view your responses as those of an ignorant, immature, and arrogant narcissist, but you are making it difficult. Ignorance, immaturity, arrogance, and narcissism are dangerous qualities in a physician. Please don't take these comments "the wrong way." 🙂

Nick

Instead of writing the above, why don't you post some cases?

 

[neurologist]

Instead of writing the above, why don't you post some cases?

OK, here's a case in the spirit of our original poster:

32 year old woman with headache. Next day she was dead. What happened?

WRONG!

She was run over by a bus on the way out of the ER!

I guess that's pretty much how Dr Neglect wants us to operate . . .
Maybe if he wouldn't "neglect" giving us some more pertinent history/exam we could have more fun than this . . .

By the way, I DO agree with Neglect about the Baylor Case of the Month website. Very cool and much more fun and educational than this thread . . .

 

[Nerdoscience]

Wait, so if we have a problem with your attitude and presentation style, but don't have a case we want to present, we can't tell you about it? Good thing you're not going into law. There are holes all over that logic.

Seriously, though, how about just giving all info asked for if you know it. You know, like they do in clinical conferences? That would be nice, and we could stop bickering.

 

[neglect]

OK, here's a case in the spirit of our original poster:

32 year old woman with headache. Next day she was dead. What happened?

WRONG!

She was run over by a bus on the way out of the ER!

I guess that's pretty much how Dr Neglect wants us to operate . . .
Maybe if he wouldn't "neglect" giving us some more pertinent history/exam we could have more fun than this . . .

By the way, I DO agree with Neglect about the Baylor Case of the Month website. Very cool and much more fun and educational than this thread . . .

Instead of writing the above, why don't you post some cases?

 

[neglect]

Wait, so if we have a problem with your attitude and presentation style, but don't have a case we want to present, we can't tell you about it? Good thing you're not going into law. There are holes all over that logic.

Seriously, though, how about just giving all info asked for if you know it. You know, like they do in clinical conferences? That would be nice, and we could stop bickering.

Instead of writing the above, why don't you post some cases?

Seriously, if you don't like the way I present the cases, then present your own. If you don't like quick cases, then don't reply with your thoughts.

 

[Sir Elroy]

Here's a case that came to our hospital. I didn't see the patient myself and I don't remember all the details, but I'll make up the less important information and adapt it to this thread. I apologize in advance if I screw this up. 🙄

Anyway, a 54 y/o caucasian male presents to clinic complaining of blurry vision for 1 week. Grossly, he appears to have esotropia.

What do you want to know history-wise?

 

[Nerdoscience]

1. Onset: sudden vs. gradual
2. In one eye, both, or only when he has both eyes open
3. Any other focal sx?

 

[Wheezy]

Thanks SirElroy😀

Well, lets start of with a few questions:

What does he mean by blurring? are things blurred (decreased acquity & central vision) or does he see two images (diplopia) or does he not notice things in the periphery (tunnel/funnel vision)?

Temporal features: Onset (acute vs subacute), did it happen previously? if so what's the pattern, has it been getting worse, better or staying the same?, is it there all the time or is it episodic?

Aggrevating or relieving factors?

Associated features: does he have a headache, jaw claudication & aches and pains all over his body? Any brain stem symptoms (vertigo, diplopia, dysarthria, dysphagia)? Motor or sensory deficits? Any autonomic features? (postural hypotension/fainting, urinary retension, sweating disturbances)?

What meds & comorbidities?

oh, and has he noticed the esotropia. is it new?

Thats enough to get us started, let's see what we can find out?

 

[neglect]

Here's a case that came to our hospital. I didn't see the patient myself and I don't remember all the details, but I'll make up the less important information and adapt it to this thread. I apologize in advance if I screw this up. 🙄

Anyway, a 54 y/o caucasian male presents to clinic complaining of blurry vision for 1 week. Grossly, he appears to have esotropia.

What do you want to know history-wise?

The thing on history is to localize between blurry vision, indicating a lens/eye problem, and double vision, indicating a problem with eye muscles. Given that the guy has esotropia, this doesn't exclude the former (he could have lifelong and uncorrected strabismus), but does make it less likely. Let's assume his blurry vision is actually double: it should be horizontal.

So if new esotropia, the eye turns in, and he has a 6th nerve on the affected side. It is pretty acute if the medial rectus hasn't relaxed yet. Let's go on assuming the 6th nerve is in isolation with no other CN or long track signs or general motor signs - including ocular CNs. From there it could be anything. If we assume it is isolated, and we'd have to be careful about that on exam, then it does lead away from a nerve or fasicle lesion (very difficult to lesion the 6th nerve in isolation, although possible), but does not localize. Or rather, localizes to head.

If you took all comers, he has a diabetic or idiopathic 6th and there's nothing to do except wait, must check for DM and if he is, then this is reassuring. If not, not.

The 6th has a long course and can get lesioned anywhere: simply from increased ICP, but no HA to make one think of pseudotumor (on the inflammatory cranial neuropathies or a meningitic process). Then any mass lesion anywhere along the course of 6: clivus, cavernous sinus and of any sort of problem behind the eye.

Further along, moving distally, one must at least consider myasthenia, even with a fixed lesion. Finally, after NM jxn comes muscle: eye myopathies or restrictions.

 

[Sir Elroy]

He says if he thinks back, he maybe has had trouble with his eyes for a couple months, but he's not sure if he's imagining that retrospectively or not. He specifically noticed the blurriness and his eyes being "crossed" when he was in the bathroom right after he woke up a week ago. Upon further questioning, he says his "blurriness" is two images next to each other.

He only has trouble when both eyes are open, especially when looking to the right. He says he adjusts by turning his whole head to the right instead of just his eyes. These symptoms are there all day long.

As far as other symptoms, he denies any weakness, numbness, coordination problems, seizures, blackouts, dysarthria, dysphagia, vertigo, or trouble walking. He gets occasional headaches, but he says he's gotten those since childhood, usually when he's tired or stressed. These haven't changed recently. No jaw claudication, autonomic symptoms or generalized fatigue. He wears glasses for reading (has since he was 42), but he's never had this specific kind of eye trouble before.

PMH: none that he knows of; he says he's always been pretty healthy, and a routine checkup six months ago went fine. He says the routine labs, including his blood sugar, after that visit were fine.

Meds: Tylenol occasionally, otherwise nothing. No herbs/alternative meds.


More history questions?

 

[neglect]

I think there are only two more pieces of information: fatiguability and is this an isolated 6th. 6th nerve, non-diabetic, needs imaging.

To some of the others, this gets futile when you don't include enough information to solve the problem on the first go round. Even in retrospect, when the mass lesion in the cavernous sinus gets imaged, will one be able to pull out the initial clues. Or, worse, when he has an ipsilateral facial on exam.

 

[Sir Elroy]

If you want to go straight to the neuro exam, here you go:

Orientation, Language, Mini-Mental: normal
Cranial Nerves: consistent with a right sixth nerve palsy, otherwise normal
Strength: normal, no fatiguability
Reflexes: normal
Sensation: normal
Coordination: normal
Gait: normal

So basically, it's an isolated sixth nerve palsy.

You're welcome to order imaging and labs, but since this is a clinic visit, those don't come back immediately. In the meantime, care to figure it out by history alone?

 

[Nerdoscience]

I've seen this isolated in MS, though it's not "textbook." It still makes me think demyelinating, but could be one of many processes, as delineated by neglect. I would want to check an MRI (mass lesions, demyelination, vascular), as well as CSF for West Nile, Lyme and VDRL, chemistries. I've seen those particular pathogens cause isolated Neuro defects. The fact that it's only one lesion makes Miller-Fisher variant GBS less likely, but chemistries would tell us something. Time course and age rule out Duane Syndrome, which is a wastebasket term anyway.

Already talked about glucose. How about BP?

May end up just being idiopathic.

 

[Callogician]

Wow...this thread really makes me want to go into neurology. I know enough to understand your analyses but not enough to have any shot of making the Dx. Keep posting guys. This is very entertaining for me.

 

[Sir Elroy]

Blood pressure for the clinic visit is 134/82, and temperature is normal. I'll also add that he hasn't had a fever or been sick recently, and there's no history of head trauma.

Other exam notes that I didn't specifically mention: no periorbital edema, and fundoscopic exam appeared normal.

I'd give CSF/lab/imaging results, but that'd end the case right there, so I'll wait just a little bit longer to see if anyone figures out the one piece of history I'm fishing for. 🙄

 

[Faebinder]

This could also be Myasthenia Ocular (though mostly young women). (someone even mentioned Myasthenia already.)


Try a dose of Edrophonium (Tensilon test), first line for Myasthenia.

If what everyone else said is not working (especially MS my first line answer), then you gonna start pointing at super zebras. Like Eaton Lambert Syndrome.

 

[neurodoc]

Well, if he's not a diabetic, you need to be very suspicious of a tumor involving the nasopharynx. Is he a smoker?

Nick