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

> An emergency case for medical students: a 34-year-old with drooping eyelids, double vision and difficulty swallowing that came on over hours. Protecting breathing, what to ask, first tests and the differential.

- Emergency Medicine · Advanced · about 20 minutes · live emergency
- Web page: https://www.medikarya.in/case-studies/34-year-old-man-with-drooping-eyelids-and-trouble-swallowing
- Work up this patient: https://www.medikarya.in/case-studies/34-year-old-man-with-drooping-eyelids-and-trouble-swallowing

## How the patient presents

A 34-year-old man woke with stomach pain and vomiting, and soon after his eyelids began to droop and he started seeing double. His wife has brought him in and answers for him.

## 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.

### Where nerve meets muscle

- Myasthenia gravis
- Botulism
- Organophosphate poisoning
- Neurotoxic snake bite

### Nerves

- Variants of Guillain-Barre syndrome

### Brain

- Brainstem stroke

### Other

- Diphtheria

## 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.

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A study guide for medical students, not medical advice. Follow your institution's protocols in practice.