A 53-Year-Old Social Media Worker With Dysphonia and Paresis

Paul P. Rega, MD

Disclosures

July 20, 2021

Physical Examination and Workup

The patient's initial vital signs in the ED include a temperature of 98.6 °F, heart rate of 102 beats/minute with sinus tachycardia, blood pressure of 116/50 mm Hg, and respiration rate of 18 breaths/minute. Her oxygen saturation level is 99%. Her score on the Glasgow Coma Scale is 15. She rates the level of her pain at 7 out of 10.

Once the patient is undressed and placed in a gown, a physical examination is performed. The results are normal except for a mildly distended abdomen with voluntary guarding along the lower quadrants. No rebound tenderness is noted. The mucous membranes are slightly dry. The results of the neurologic examination are grossly intact.

An intravenous (IV) line is inserted, and blood is drawn for laboratory studies. The results of a complete blood cell count, comprehensive metabolic panel, and urinalysis are normal. Plain abdominal radiography reveals distended loops of bowel and air-fluid levels. Similar radiographic findings are shown below in a different patient (Figure 1).

Figure 1.

An abdominal CT scan with IV contrast confirms the dilated loops of small bowel but reveals no evidence of a mechanical obstruction. Figure 2 shows an example of an intestinal obstruction on a CT scan in a different patient.

Figure 2.

After a consultation finds no evidence of an acute abdomen requiring surgery, the patient is sent to the ED observation unit for placement of a nasogastric tube, IV hydration, analgesia, and monitoring.

Over the course of 4-5 hours in the observation unit, the patient begins to see double, and her speech becomes less intelligible. She also complains of shortness of breath. Her temperature is 98.2 °F, heart rate is 52 beats/minute, blood pressure is 92/52 mm Hg, and respiration rate is 28 breaths/minute. Her oxygen saturation level is 97%. Her score on the Glasgow Coma Scale is 14-15. She rates the level of her pain at 2 out of 10.

The physician on duty is unable to see the patient immediately and orders a CT scan of the brain, repeated blood tests, and arterial blood gas analysis. The results of the brain CT scan are normal. The arterial blood gas analysis demonstrates a moderate respiratory acidosis. The findings are:

  • Arterial blood pH: 7.32 (reference range, 7.35-7.45)

  • Partial pressure of oxygen (Po2): 94 mm Hg (reference range, 75-100 mm Hg)

  • Partial pressure of carbon dioxide (Pco2): 56 mm Hg (reference range, 35-45 mm Hg)

When the physician returns to see the patient, he notes bilateral ptosis, dysphonia, dysarthria, and bilateral cranial nerve VI paresis.

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