A 47-Year-Old With Diplopia, Limb Tingling, and Imbalance

Sujatha R. Borra, MD; Rahul R. Borra; Darshan Rola; Neal T. Patel


August 03, 2021

Physical Examination and Workup

The patient is oriented to person, place, and time and does not appear in any distress. His weight is 170 lb (77.1 kg), and his height is 5 ft 11 in (180.3 cm).

The patient's temperature is 98.3° F (36.8° C). His blood pressure is 116/72 mm Hg, his pulse is 70 beats/min and regular, and his respiration rate is 14 breaths/min and unlabored.

Ocular examination reveals impairment of the lateral gaze of the right eye. Similar findings in a different patient are shown below (Figure 1). His pupils are equal, round, and reactive to light and accommodation bilaterally.

Figure 1.

Patellar and Achilles reflexes are 0+ bilaterally. Light touch sensation is diminished in the lower extremities bilaterally in a nondermatomal distribution. Discrimination between sharp and dull touch is intact. Heel-to-shin testing is moderately impaired bilaterally, with ataxic gait and a wide base.

MRI of the brain reveals no abnormalities. Figure 2 shows head CT findings similar to those seen in the patient in this case. Figure 3 shows a T1-weighted MRI scan of the spine that is similar to the one for the patient in this case.

Figure 2.

Figure 3.

A lumbar puncture is performed. Analysis of the cerebrospinal fluid shows normal levels of glucose and white blood cells (WBCs); however, a very mild increase in the protein level is noted. The results of a comprehensive metabolic panel are normal. The only abnormal result on complete blood cell count is a WBC count of 13,000 cells/µL. The blood urea nitrogen/creatinine ratio is within normal limits, and urinalysis reveals no pyuria or red blood cell casts.


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