Case of the Month

Case of the Month #3: Presentation

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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

PE

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.
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andygrock

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1 comment for “Case of the Month #3: Presentation”

  1. ablumenberg
    September 11, 2014 at 1:16 pm

    Patient has inability to raise left eyelid completely. This is ptosis.
    There are two muscles involved in lifting the eyelid, the levator palpebrae superioris (occulomotor nerve) and Muller’s muscle aka superior tarsal muscle (sympathetic innervation).

    The differential diagnosis includes:
    Aponeurotic ptosis – most common cause of new isolated ptosis in adults. Caused by separation of the levator aponeurosis.
    Congenital – worthy of a write up if first presentation is in an adult
    Occulomotor nerve palsy – would be expected to have EOM abnormalities as CNIII mediates many eye movements
    Horner’s syndrome – loss of sympathetic tone to Muller’s muscle. Look for ipsilateral miosis, anhydrosis, and change of skin color. The sympathetic plexus wraps around the carotid so check for carotid aneurysm, carotid sinus mass, etc. Apical lung tumors may also present as Horner’s.
    Myesthenia Gravis: symptoms tend to vary throughout day and MG causes fatiguable muscle weakness. Other muscle groups would likely also be affected.
    Botox – Did the patient visit a sloppy cosmetic guru recently?
    Mass – is there a lid abscess or funky growth on the eyelid that makes it heavier?
    Diabetes – mononeuropathy may be seen
    Stroke – As feared, lid lag may be one of several features of a stroke but isolated ptosis for 3 weeks does not warrant a stroke code. Tiny stroke affecting CNIII nucleus would still be expected to have EOM weakness.

    Diagnostic plan:
    Evaluate for associated muscle weakness, CNIII deficit, different pupil size, neck masses, associated skin changes. Ask relevant historical questions e.g, swallowing difficulty or recent botox. Consider doing a finger stick glucose.

    Leading diagnosis: Aponeurotic ptosis

    Treatment: reassurance and follow up

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