Case 5
CASE 5: DESCRIPTION
35 year-old left-handed woman who does “skin popping” (ie uses heroin subcutaneously) presents to the ER with fever and progressively worsening double vision followed by droopy eyelids, then slurred speech, choking on food and difficulty breathing over the past week. She reports feeling weak and fatigued but has no problems thinking or walking around. She has no numbness or tingling.
SHx: unstable housing, identifies as Caucasian
General Exam
T 39 degrees C, BP 160/90, HR 110, RR 24, O2 sat 95%
Respir: labored respirations
Skin: multiple abscesses on the skin with erythema and draining pus (see Figure B)
Neurologic Exam
MS: Alert, oriented, follows all commands, intact language, naming, repetition, fair historian
CN: VFFTC, pupils 6mm bilaterally and sluggish reaction to light, reports double vision worst when looking to the right or left, bilateral ptosis with eyelids covering the midpoint of both pupils (see Figure A), symmetric bilateral eye closure weakness, unable to puff out cheeks or keep mouth muscles tightly closed (ie symmetric bilateral facial weakness), slurred speech – dysarthria, poor cough and gag, neck flexion and extension weakness – unable to lift head off of the bed
Motor: cachexic bulk, upper extremities 4/5 strength with normal to low tone, lower extremities 5/5 with normal tone
Reflexes: 2+ throughout, toes down
Sensation: intact to light touch, pinprick, proprioception
Coordination: intact FNF, HKS, finger taps/foot taps
Gait: normal