Drooping eyelids, double vision and trouble swallowing in a 34-year-old: a case to work up

Why drooping eyelids, double vision and difficulty swallowing matters

When the eyelids droop, the eyes stop moving together and swallowing fails over hours, the problem is usually in the nerves, where nerve meets muscle, or in the brainstem, and breathing may be next. Protect the airway and think about toxins as well as nerve disease.

What to ask in the history

• The timeline, symptom by symptom
• Everything he ate in the last day or two; is anyone else ill
• Snake or insect bites; pesticides
• Alcohol, drugs
• Weakness elsewhere, breathing
• Blurred vision, dry mouth
• Numbness
• Previous episodes, or weakness that gets worse through the day
• Medicines

Red flags

• Breathlessness, a weak cough, saliva pooling in the mouth
• Weakness spreading quickly
• Other people with the same symptoms

What to examine

• Breathing: rate, counting in one breath, vital capacity
• Eyelids, eye movements, pupils
• Face, palate, gag, swallowing
• Power, reflexes, sensation in the limbs
• Bite marks
• Pulse and blood pressure

First investigations

• Vital capacity, repeated
• Blood gas
• Glucose, electrolytes including magnesium and calcium
• Creatine kinase
• MRI of the brain
• Nerve conduction studies
• Antibody tests for myasthenia
• Toxin testing through the public health laboratory
• Cholinesterase if pesticide exposure is possible

Differential diagnosis of drooping eyelids, double vision and difficulty swallowing

Grouped, not ranked. Which one fits this patient is for you to work out in the case.

Common mistakes

• Waiting for the oxygen saturation to fall before supporting breathing.
• Not asking what he ate and whether anyone else is ill.
• Missing a snake bite.