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حالة سريرية

كتابة حرة وطرح موضوع النقاش!
A previously healthy 50-year-old woman comes to the physician because of double vision for
three days. Her temperature is 37 C (98.6 F). The patient denies nausea or vomiting.
Examination reveals drooping of the right eyelid and slight divergence of the right eye.
Extraocular movements are limited in all directions, except laterally. The right pupil is larger
than the left and poorly reactive to light. Examination of the fundus fails to reveal papilledema.
Which of the following is the most likely underlying condition?
A. Aneurysm of the posterior communicating artery
B. Carcinoma of the right pulmonary apex
C. Diabetes mellitus
D. Giant cell arteritis
E. Syphilis
F. Systemic hypertension
by

The correct answer is A. This patient displays signs of oculomotor palsy, with
restriction of the eye movements in all directions (except laterally, due to preservation of
the sixth cranial nerve, the abducens)
, and ptosis. Dilatation of the pupil, which fails to
react to light, is a sign of intracranial compression of the third, or oculomotor cranial
nerve
. This should prompt search for an underlying surgical cause of oculomotor palsy.
Uncal herniation and aneurysm of the posterior communicating artery are the two most
common surgical conditions leading to oculomotor palsy.
In the absence of clinical
evidence of increased intracranial pressure, it may be assumed that the patient has an
aneurysm of the posterior communicating artery until proven otherwise.
Cerebral
angiography is the investigation of choice to confirm the diagnosis.
All of the most common medical causes of oculomotor nerve palsy result in paresis of
extraocular movements and ptosis, but the pupillary light reflex is preserved. These
conditions include diabetes mellitus (choice C), giant cell arteritis (choice D), syphilis
(choice E) and systemic hypertension (choice F).
Carcinoma of the right pulmonary apex (choice B) may result in Horner syndrome
(miosis, ptosis, enophthalmos, and loss of sweating on the affected hemiface) due to
infiltration of the cervical autonomic ganglia
qusei
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