A 65-Year-Old Woman with a History of Diabetes Mellitus and Hypertension

question 105

Multiple Choice

A 65-year-old woman with a history of diabetes mellitus and hypertension is brought to the emergency department due to double vision and right eye pain.  She awoke 2 days ago with right periorbital pain, and several hours later, she noticed double vision that became worse with accommodation.  The double vision has been persistent and does not fluctuate throughout the day.  The patient has had no headaches, blurry vision, dysarthria, dysphasia, weakness, numbness, or balance problems.  Medications include aspirin, lisinopril, and metformin.  The patient does not use tobacco, alcohol, or illicit drugs.
Blood pressure is 150/90 mm Hg seated and pulse is 80/min.  Neurologic examination shows both horizontal and vertical binocular diplopia with left lateral and upward gazes.  There is complete ptosis of the right eyelid, with the eyeball in the down-and-out position.  The right pupil is 5 mm, midposition, and nonreactive to light; the left pupil is 3 mm, midposition, and reactive to light.  The anisocoria improves with the ambient light off.  No eye proptosis, conjunctival injection, periorbital edema, chemosis, or ocular bruit is present.  Funduscopic examination reveals no papilledema.  The rest of the neurologic examination is normal.  Which of the following is the most appropriate next step in management of this patient?

• A)MR angiography of the head
• B)MRI diffusion-weighted sequence of the brain
• C)Serum acetylcholine receptor antibody testing
• D)Serum creatine phosphokinase and aldolase testing
• E)Supportive care

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