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em@3am

EM@3AM: Oculomotor Nerve Palsy

A 50-year-old female with no past medical history presents to the ED with a diffuse, constant headache onset a few weeks. The patient describes droopiness of the left eye and double vision associated with specific directional movements of the eye. On exam, you note ptosis of the left eye with findings as indicated in the photograph below (inability to adduct, ability to abduct). The left pupil is dilated at 5mm and minimally reactive to light; the right pupil is 3mm and reactive. The remaining cranial nerve testing and components of the neurological exam are normal.

em@3am

EM@3AM: Basilar Artery Occlusion

A 68-year-old male with a past medical history of hypertension, diabetes mellitus, and CAD with a drug eluting stent placed 2 months ago presents with dizziness and vomiting that began 3 hours ago. He has been having “issues with [his] eyes” today and “not feeling quite right.”  Vital signs include BP 165/83, HR 81, RR 18, SpO2 96%. On exam, you notice he has dysarthric speech, limb ataxia, and vertical gaze palsy, which he reports is new. You perform a NIHSS which scores a 3 for mild dysarthria and ataxia in two limbs.

em@3am

EM@3AM: Cerebellar Stroke

A 53-year-old female with a history of hypertension presents to the ED with headache and dizziness.  Her symptoms have been constant over the last two weeks. Triage vital signs (VS) include BP 163/89, HR 78, T 98.4, RR 14, SpO2 98% on room air. On exam, no nystagmus is noted. Her extraocular movements and cranial nerves II-XII are intact, strength of all four extremities is 5/5 without any focal weakness, and there are no appreciable sensory deficits. There is, however, dysmetria of the right upper extremity. What should you consider?