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DIAG 2740 Chapter 13 Case Studies

DIAG 2740 Chapter 13 Case Studies - Chapter 13 Cases Case#1...

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Chapter 13 Cases Case #1 Double Vision and Unilateral Eye Pain Chief Complaint A 48 year old woman came to the emergency room with worsening left eye pain and intermittent double vision. History Approximately 4-5 years ago, the patient had begun to have left frontal and left retro-orbital headaches that occurred intermittently at first, and then went on an almost daily basis. The headaches continued to occur but were relieved by ibuprofen. One and a half years prior to presentation she began to have intermittent drooping of the left eyelid and dilation of the left pupil. She also noticed that her left eye occasionally drifted to the left, causing diplopia. The patient was observant, and she noticed that her diplopia was worse when looking to the right. When covering each eye alternately, she reported that the two images did not overlap. In fact, the image from the left eye appeared to the right, and slightly above the image from her right eye. These symptoms gradually progressed from intermittent to continuous, and her headaches were no longer relieved by up to 12 ibuprofen tablets per day, so she came to the emergency room. Physical examination Vital signs: Temperature = 98.7º Pulse = 78 BP = 180/90 Neck: supple with no bruits Lungs: clear Heart: regular rate with no murmurs Abdomen: soft, nontender Neurologic exam: Mental status : alert and oriented x3. Speech fluent, with intact naming and repetition. Recall was 3/3 words after 5 minutes. Cranial nerves : Visual fields full. Fundi normal. Right pupil 4 mm, constricting to 3 mm with direct and consensual light stimulation, and accommodation. Left pupil 6 mm, with no direct or consensual response to light and no response to accommodation. Left eye had limited but not absent upgaze, downgaze, and adduction. Normal eye movements. Left ptosis, with left palpebral fissure 6 mm and right 9 mm. Corneal reflexes intact. Facial sensation intact. Face symmetrical, other than the ptosis already described. Normal palate and tongue movements. Motor : no drift. Normal tone. Strength 5/5 throughout. Reflexes : all grade 2+, with normal plantar response. Coordination : normal finger nose and heel shin. Sensory : intact light touch, pin prick, vibration, and joint position sense. Normal graphesthesia, no extinction.
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Localization and differential diagnosis 1. On the basis of the signs and symptoms shown in bold above, which cranial nerve is involved? 2. What is the most likely cause of cranial nerve involvement? Case #2 A Diabetic With Horizontal Diplopia Minicase A 54 year old man with a history of diabetes awoke one morning with horizontal diplopia that increased on gaze to the left and decreased with gaze to the right. He initially had some pain in the left preorbital area, which resolved after a few days. Exam was normal except for incomplete abduction of the left eye.
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DIAG 2740 Chapter 13 Case Studies - Chapter 13 Cases Case#1...

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