Case 7
CASE 7: DESCRIPTION
63 year-old right handed woman with hypertension and diabetes mellitus type 2 presents to the emergency room with vision changes. She awoke this morning with mild pain in her right eye and blurry vision. When asked specifically, she notes that she is seeing double with vision made all the more difficult by a right eyelid that doesn’t want to open the whole way. She denies prior similar symptoms. There was no warning sign before this happened. Denies vision loss, scotomata, zigzag lines, photophobia, phonophobia, nausea, vomiting, jaw claudication.
SHx: identifies as Black
Vitals: T 37, BP 155/130, HR 84 regular, RR 12, O2 sat 99% RA.
General Exam: moderate abdominal obesity, appears stated age, acanthosis nigricans
Neurologic Exam:
Mental status: Alert, oriented x 3, appropriate, fluent speech. Able to follow complex commands.
CN: Normal fundoscopic exam. VFFTC, Pupils are equal, round and reactive to light with normal accommodation. Moderate right ptosis is noted. Extraocular movements are notable for restriction of right eye adduction, elevation and depression. Reports double vision when looking to the left. In primary gaze, right eye is depressed and abducted compared to left eye, i.e. “down and out.” Face otherwise symmetric and strong. Hearing intact, intact palate elevation, intact SCM, intact tongue strength
Motor: 5/5 strength throughout. Normal bulk and tone.
Sensory: unremarkable
Reflexes: 2+ normal and symmetric, toes down
Coordination: No ataxia
Gait: Normal, intact tandem