INITIAL OFFICE EVALUATION
A 31-year-old black woman, neat and intelligent, but vague as to when symptoms started. It was, she thinks, possibly 2 to
3 months ago that she first felt pressure behind her eyes, and she was seen in the eye clinic. She thinks that it was about a week ago when she first noticed that if she looked off to either side, she saw double. This has remained the same, and there is no longer a pressure feeling in her eyes. She denies difficulty with mastication, deglutition, or use of extremities.
3 months ago that she first felt pressure behind her eyes, and she was seen in the eye clinic. She thinks that it was about a week ago when she first noticed that if she looked off to either side, she saw double. This has remained the same, and there is no longer a pressure feeling in her eyes. She denies difficulty with mastication, deglutition, or use of extremities.
PHYSICAL EXAMINATION
The disks are flat. One cannot be sure of the EOM weakness on observing the eyes in all of the cardinal directions of gaze; however, there is uncrossed diplopia on lateral gaze in either direction, indicating bilateral abducens muscle weakness. On repetitive eye movements, there is minimal ptosis, slightly more on the left than on the right. Other cranial nerves are intact. DTRs 1 to 2+ and are equal. Plantar responses are downward. There is excellent strength and coordination in the face, neck, and extremity musculature, without evidence of fatigue. No sensory deficits are present.
IMPRESSION
Patient apparently has bilateral abducens muscle weakness. High on the list of possibilities would be myasthenia gravis and/or thyrotoxicosis. An intrinsic brain stem lesion or a basilar skull fracture also must be ruled out.
Patient is to have skull x-rays, PA and lateral chest x-ray, T3, and 2-hour postprandial blood sugar. A Tensilon test was attempted today, but patient has very bad veins, and enough Tensilon to carry out the test adequately was not possible to inject. She is to return in a week for a Prostigmin test.
FOOTNOTE
Lines 7-38. The physician dictates some inappropriate commas and semicolons, which were corrected.
Line 8. Alternative: 2-3.
Line 14. The physician mispronounces deglutition as deglutination.
Line 17. Alternative: Discs.
Line 23. Alternative: 1+ to 2+.
Lines 31, 32. The physician does not dictate fracture after basilar skull, but it was added for clarity.
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