Case of the Month #3: Presentation

by andygrock • September 5, 2014 • 1 Comment

This is a fictitious patient seen at a fictitious hospital called Janus General. Don’t believe me? I’m on staff there – see

54 yo male, past medical history HTN, sent by his primary doctor to the ED for “rule out stroke”. He is complaining that his left upper eye lid feels heavier than usual for about 2-3 weeks. He doesn’t know what makes it better or worse and denies any trauma. ROS otherwise neg.

VS 80, 130/70, 15, 100% on RA

Heart/lungs/abd unremarkable.

Neuro exam: CN II-XII intact except for limited ability to raise left eyelid completely. strength 5/5 with sensation intact to light touch throughout. Finger to nose intact, rhomberg nml, gait/heel walk/toe walk/tandem walk normal.

Assessment and Plan: 54 yo male, pmhx htn, here for L eye heaviness. Sent by primary doctor to rule out stroke

Please provide your answer in the form of an appropriate plan for this fake case’s note. Include a differential diagnosis, diagnostic plan, leading diagnosis, and treatments needed in the ED.

By Dr. Andrew Grock

The views expressed on this blog are the author's own and do not reflect the views of their employer. Please read our full disclaimer here. Any references to clinical cases refer to patients treated at a virtual hospital, Janus General Hospital.

Bio
Latest Posts

andygrock

Resident Editor In Chief of blog.clinicalmonster.com.
Co-Founder and Co-Director of the ALiEM AIR Executive Board - Check it out here: http://www.aliem.com/aliem-approved-instructional-resources-air-series/
Resident at Kings County Hospital