Abnormal Eye Movement and Agitated Delirium in a 26-Year-Old

Caroline Tschibelu, MD


January 20, 2021

Physical Examination and Workup

Upon physical examination, the patient has a blood pressure of 165/105 mm Hg, pulse of 128 beats/min, respiratory rate of 20 breaths/min, pulse oximetry of 98% on room air, and a temperature of 100.6°F (38.1°C).

The patient is a thin woman who seems agitated and restless but complies with the examination. The lung examination reveals clear breath sounds in all fields. Her heart has a regular rhythm, and no murmur is appreciated.

Upon neurologic evaluation, she is alert and oriented to date but not to time or place. Her speech is clear and fluent, with good repetition, comprehension, and naming. She recalls 1 out of 3 objects at 5 minutes. No tenderness or signs of trauma are found over the scalp and neck. No proptosis, lid swelling, conjunctival injection, or chemosis is observed.

The patient is able to identify a pen and a clock. She can count fingers and has an intact bitemporal visual field. Extraocular muscles are intact upon examination; she is able to look from right to left as well as up and down. Spontaneous right ocular clonus is observed. Her pupils are 2 mm and are reactive to light. Sensory examination of her face is unremarkable. Her tongue and uvula are midline, with a positive gag reflex. Her hearing test findings are symmetric. Shoulder-shrug findings are equal on both sides. Strength is 5/5 in the upper and lower extremities.

Sensory examination findings reveal symmetry to light touch, pinprick, temperature, vibration, and proprioception. The patient's reflexes are 2+, except in the lower extremities, where bilateral hyperreflexia is observed. She is able to perform rapid alternating movements. The remainder of her physical examination findings are unremarkable.

An ECG reveals normal sinus at a rate of 128 beats/min, without ST-T wave changes. Head CT is performed, and an example similar to the findings in this case is shown below.

Figure 1.

A urine pregnancy test result is negative. Laboratory analyses performed in the ED include a complete blood cell count, metabolic panel, hepatic panel with lipase, and troponin level. Laboratory test findings are remarkable for a white blood cell count of 12.4 × 103 cells/µL (reference range, 4.2-11.0 × 103 cells/µL), with 69% segmented neutrophils (54%-62%) and bandemia of 2% (3%-5%), and a hemoglobin level of 11.6 g/dL (reference range for women, 12-15 g/dL). Her troponin level is 0.5 ng/mL (reference range, 0-0.4 ng/mL). The remainder of laboratory test findings, including a toxicology screen and creatine phosphokinase level, were within normal limits.

The patient was given acetaminophen for the low-grade fever. Intravenous fluids were started, and she was admitted to the medicine floor.


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