A 44-Year-Old With a Headache, Photophobia, and Phonophobia

James Lee, MD; Stephanie Oh, PhD; Gaurav Gupta, MD


November 13, 2019

Physical Examination and Workup

Upon physical examination, the patient is noted to be of average build, with normal body mass index. Her head is normocephalic and atraumatic. She is oriented to person, place, and time. Her speech is fluent and clear, and she is able to follow complex commands. Her pupils are equal, round, and reactive to light.

The fundi are normal, and spontaneous venous pulsations are present. Extraocular movements are intact, and visual fields are full to visual confrontation. A decreased palpebral fissure is noted in her left eye, along with weakness in left eye closure and an inability to furrow her left eyebrow. She is also noted to have decreased pinprick and cold sensation along the left V2/V3 distribution. Her muscles of mastication are normal. She has prominent left facial asymmetry, with flattening of the nasolabial fold. Her hearing is grossly symmetrical, with subjective hypersensitivity to sound in her left ear. Her palate elevates in the midline, and the tongue has normal motion without fasciculations. Weber and Rinne test results are unremarkable. Finger-to-nose, heel-to-shin, and tandem gait are normal.

She has normal muscle bulk and tone; strength and sensation are normal in her upper and lower extremities. Her deep tendon reflexes are normal throughout, except 3+ in her bilateral patellar tendons. Her toes are downgoing bilaterally, with no clonus.

Serum findings were unremarkable. Brain MRI with and without contrast (with special attention given to the internal auditory canals) and electromyography (EMG) were performed. An example similar to the MRI findings in this patient is shown in the image below.

Figure 1.


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