A 49-year-old female saw a primary care physician complaining of intermittent double vision of 2 months duration. The double vision came and went, sometimes vertical and sometimes horizontal. Each episode lasted for a few hours to several hours. She was sent to see a neurologist, who urgently sent her for a magnetic resonance imaging (MRI) of the head, revealing multiple embolic infarcts of the brain stem. Thus, she was advised for urgent admission to a hospital. She is a previously generally healthy woman who takes non-steroidal agents for arthritis, but otherwise, she takes no other regular medications and works as a child care provider at home. She denies fever, chills, headache, night sweats, weight loss, nausea, or vomiting.
Examination
On arrival, the patient was haemodynamically stable. Cardiovascular examination was unremarkable with an undisplaced point of maximum impulse, normal S1 and S2, no murmurs or friction rub, and normal breath sound on auscultation. Pertinent neurological examination findings include a mild weakness in adduction of the left eye with no nystagmus. Finger-to-nose testing, however, revealed mild dysmetria on past-pointing on the right side only. She also demonstrated mild dysmetria on heel-to-shin testing on the right. Gait assessment revealed mild truncal ataxia with difficulty walking and tandem gait without assistance. Deep tendon reflexes were symmetrical 1+/5 in biceps, triceps, 1/5 ankle jerks.
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