𝗪𝗵𝗲𝗻 𝗗𝗶𝗽𝗹𝗼𝗽𝗶𝗮 & 𝗩𝗼𝗺𝗶𝘁𝗶𝗻𝗴 𝗶𝗻 𝗮 𝗧𝗲𝗲𝗻 𝗨𝗻𝗳𝗼𝗹𝗱𝗲𝗱 �…

𝗪𝗵𝗲𝗻 𝗗𝗶𝗽𝗹𝗼𝗽𝗶𝗮 & 𝗩𝗼𝗺𝗶𝘁𝗶𝗻𝗴 𝗶𝗻 𝗮 𝗧𝗲𝗲𝗻 𝗨𝗻𝗳𝗼𝗹𝗱𝗲𝗱 𝗮𝗻 𝗨𝗻𝗲𝘅𝗽𝗲𝗰𝘁𝗲𝗱 𝗡𝗲𝘂𝗿𝗼𝗹𝗼𝗴𝗶𝗰𝗮𝗹 𝗣𝘂𝘇𝘇𝗹𝗲

A 𝟭𝟲-𝘆𝗲𝗮𝗿-𝗼𝗹𝗱 𝗴𝗶𝗿𝗹, 𝗞𝗿𝗮𝘁𝗶𝗸𝗮 (𝗻𝗮𝗺𝗲 𝗰𝗵𝗮𝗻𝗴𝗲𝗱 ) presented to our ER with: * 𝗔𝗰𝘂𝘁𝗲 𝗼𝗻𝘀𝗲𝘁 𝘃𝗼𝗺𝗶𝘁𝗶𝗻𝗴 𝗮𝗻𝗱 𝗵𝗲𝗮𝗱𝗮𝗰𝗵𝗲 𝗳𝗼𝗿 𝟮 𝗱𝗮𝘆𝘀 * 𝗗𝗼𝘂𝗯𝗹𝗲 𝘃𝗶𝘀𝗶𝗼𝗻 (𝗱𝗶𝗽𝗹𝗼𝗽𝗶𝗮) 𝗳𝗼𝗿 𝟭 𝗱𝗮𝘆

➡️ 𝗢𝗻 𝗘𝘅𝗮𝗺𝗶𝗻𝗮𝘁𝗶𝗼𝗻: * Conscious, alert * Vitals stable (BP normal ) * 𝗕𝗶𝗹𝗮𝘁𝗲𝗿𝗮𝗹 𝗹𝗮𝘁𝗲𝗿𝗮𝗹 𝗿𝗲𝗰𝘁𝘂𝘀 𝗽𝗮𝗹𝘀𝘆 (abducens nerve palsy) * 𝗗𝗲𝗰𝗿𝗲𝗮𝘀𝗲𝗱 𝘃𝗶𝘀𝘂𝗮𝗹 𝗮𝗰𝘂𝗶𝘁𝘆 * 𝗔𝘁𝗮𝘅𝗶𝗰 𝗴𝗮𝗶𝘁 (possibly secondary to vision loss) * 𝗔𝗿𝗲𝗳𝗹𝗲𝘅𝗶𝗮 (DTRs not elicited) * Plantar: bilateral flexor * No neck rigidity * 𝗙𝘂𝗻𝗱𝘂𝘀: 𝗡𝗼𝗿𝗺𝗮𝗹

➡️ Initial Investigations: * 𝗠𝗥𝗜 𝗕𝗿𝗮𝗶𝗻: 𝗡𝗼𝗿𝗺𝗮𝗹 * 𝗡𝗖𝗩: 𝗡𝗼𝗿𝗺𝗮𝗹 * 𝗠𝗥𝗩: 𝗣𝗹𝗮𝗻𝗻𝗲𝗱

✅ 𝗗𝗶𝗳𝗳𝗲𝗿𝗲𝗻𝘁𝗶𝗮𝗹𝘀 𝗖𝗼𝗻𝘀𝗶𝗱𝗲𝗿𝗲𝗱: * 𝗖𝗲𝗿𝗲𝗯𝗿𝗮𝗹 𝗦𝗶𝗻𝗼𝘃𝗲𝗻𝗼𝘂𝘀 𝗧𝗵𝗿𝗼𝗺𝗯𝗼𝘀𝗶𝘀 (𝗖𝗦𝗩𝗧) – pending MRV * 𝗚𝘂𝗶𝗹𝗹𝗮𝗶𝗻-𝗕𝗮𝗿𝗿𝗲́ 𝗦𝘆𝗻𝗱𝗿𝗼𝗺𝗲 – 𝗠𝗶𝗹𝗹𝗲𝗿 𝗙𝗶𝘀𝗵𝗲𝗿 𝘃𝗮𝗿𝗶𝗮𝗻𝘁 (Ophthalmoplegia, Ataxia, Areflexia) * 𝗔𝗗𝗘𝗠 – less likely due to normal MRI * 𝗡𝗲𝘂𝗿𝗼𝗺𝘆𝗲𝗹𝗶𝘁𝗶𝘀 𝗢𝗽𝘁𝗶𝗰𝗮 (𝗡𝗠𝗢) – work-up to be done

✅ 𝗞𝗲𝘆 𝗧𝗮𝗸𝗲𝗮𝘄𝗮𝘆: 𝗡𝗼𝘁 𝗮𝗹𝗹 𝗱𝗶𝗽𝗹𝗼𝗽𝗶𝗮 𝗮𝗻𝗱 𝗵𝗲𝗮𝗱𝗮𝗰𝗵𝗲 𝗶𝗻 𝗰𝗵𝗶𝗹𝗱𝗿𝗲𝗻 𝗶𝗻𝗱𝗶𝗰𝗮𝘁𝗲 𝗿𝗮𝗶𝘀𝗲𝗱 𝗜𝗖𝗣 𝗼𝗿 𝗺𝗲𝗻𝗶𝗻𝗴𝗶𝘁𝗶𝘀.

✅ What else would you consider and what additional steps would you plan next?