A 38-Year-Old Man With Double Vision, Numbness, and Headache

Olusegun John Oluwole, MBBS

Disclosures

July 28, 2020

Physical Examination and Workup

Upon examination, the patient is alert and oriented. He demonstrates some aversion to light and prefers to be examined in the dark as much as possible. He is afebrile, with a temperature of 98.6°F (37°C). He shows some evidence of dehydration. He has no rash or joint tenderness. He has a respiratory rate of 16 breaths/min, with vesicular breath sounds and no adventitious sounds.

Cardiovascular examination reveals a regular pulse at 80 beats/min, normal blood pressure at 110/70 mm Hg, normally located cardiac apex, and normal S1 and S2 heart sounds. His abdomen is flat and nontender. He has no palpable organ enlargement, and his bowel sounds demonstrate normal activity.

Upon neurologic examination, he is fully awake and aware and has no dysphasia or dysarthria. He has no neck stiffness or any other signs of meningeal irritation. His pupils are round, mid-sized, and reactive to light bilaterally. He displays normal visual acuity in both eyes using a bedside Snellen chart. He has normal visual fields, and his optic discs appear normal bilaterally. Examination of ocular movements reveals weakness of the left superior and inferior oblique muscles. His facial sensation is normal, and he has no facial weakness. He has normal gag reflex and tongue movements. In his limbs, he has right hemiparesis of grade 4/5 on manual muscle testing. He also has impaired coordination in the right arm on finger-nose testing, as well as on rapid alternating hand movements (dysdiadochokinesia). He shows diminished light touch sensation in the right upper and lower limbs.

Baseline laboratory analysis are all normal, including random blood glucose level, complete blood count, C-reactive protein level, erythrocyte sedimentation rate, kidney function test results, electrolyte levels, and liver function test results. An urgent plain head CT scan is shown in Figure 1.

Figure 1.

Subsequent head MRI is performed (Figures 2 and 3).

Figure 2.

Figure 3.

Results of basic cerebrospinal fluid (CSF) analysis are:

  • Opening pressure: 15 cm H2O

  • Appearance: Colorless

  • Cell count: 2 cells/µL (100% mononuclear cells)

  • Red blood cells: None

  • Protein level: 35 mg/dL

  • Glucose level: 50 mg/dL

  • Xanthochromia: Absent

  • Gram stain: No organisms seen

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