Question

A 74 year old man presents with double vision. He first noticed this several months ago, and although his symptoms wax and wane, he now experiences daily episodes of ""seeing double,"" most frequently in the evenings. He also reports increased generalized fatigue and notes that he sometimes gets so tired at dinner that he ""can hardly chew"" his food. Past medical history includes osteoarthritis, hypertension, and abdominal aortic aneurysm repair. Physical examination reveals a comfortable, age-appropriate elderly gentleman with mild dysarthria. Cardiac auscultation reveals both an S4 and a 2/6 holosystolic murmur heard best at the left upper sternal border with radiation to the carotids. On neurologic exam, the patient has 5/5 strength proximally and distally. Sensation is intact and reflexes are 2+ throughout. Ocular movements are sluggish but intact in all directions. The patient has mild bilateral ptosis, which is noted to increase with sustained upward gaze. Stroking the bottom of the foot results in downward deflection of the great toe bilaterally. Which of the following is the most appropriate next step in diagnosis?

A. Administer IV edrophonium
B. CT of the chest
C. MRI/MRA of brain and cerebral vessels
D. Temporal artery biopsy
E. CSF examination for oligoclonal bands

Answer 1

The most appropriate next step in diagnosis for a 74-year-old man presenting with double vision, fatigue, and ptosis is an MRI/MRA of the brain and cerebral vessels. These symptoms, along with the presence of a holosystolic murmur and bilateral ptosis that worsens with upward gaze, are suggestive of a possible neuromuscular junction disorder called myasthenia gravis.

Step-by-step explanation:

The most appropriate next step in diagnosis for a 74-year-old man presenting with double vision, fatigue, and ptosis is an MRI/MRA of the brain and cerebral vessels. These symptoms, along with the presence of a holosystolic murmur and bilateral ptosis that worsens with upward gaze, are suggestive of a possible neuromuscular junction disorder called myasthenia gravis. The MRI/MRA can help identify any abnormalities in the brain and cerebral vessels that may be contributing to the patient's symptoms.