![]() It can be a problem with the eye muscles. “There are lots of causes for double vision/eyelid drooping. Neck-scars, carotid pulse, palpate for LNs, goitre, trachea position, auscultate for carotid bruits.Examine the hands for wasting, APB power, FDI power, sensation C8-T1, clubbing, DM fingerprick marks.Chest: gynaecomastia, apex beat, PPM scar, auscultate heart sounds (murmur), auscultate lungs (bronchiectasis).Ask to close eyes tightly then open (delayed eye opening) Face and neck: frontal balding, myopathic facies, cataracts, palpate temporalis and masseter when patient clenches teeth (wasted and weak), palpate sternocleidomastoid (wasted and weak) and observe/palpate for a goitre.Pulse check, look for diabetic fingerpick marks.Percussion myotonia (use tendon hammer to tap thenar eminence, the thumb flexes).Shake patient’s hand (delay before grip release), ask to repeatedly open and close fist.Don’t miss evidence of other autoimmune conditions e.g.Resp: chest expansion and offer to do FVC.Look for a sternotomy scar (thymectomy), spirometer, gastrostomy/NG tube, does the patient appear cushingoid.Test speech (count to 50) ?fatiguability.Ask to do ‘chicken wing arm exercises 10-20 times’ then retest power (weaker after exercise). Test power of elbow flexion/extension, shoulder abduction.Neck flexion and extension against resistance.Test eye closure (peek sign) and test lip closure.Quick neuro assessment: tone, power, sensation (sensation is normal in myasthenia and myotonic dystrophy), reflexes (reduced/absent in myotonic dystrophy), coordination.Temporal arteries palpation (if age >50).Make a point of testing CN 4 (ask to look down and in) and CN 6 (ask to look laterally) Eye movements and ask if gets double vision (observe for opthalmoplegia) and fatiguability on looking up for 20 seconds (myasthenia).Inspect: ptosis (uni/bilateral, symmetrical/asymmetrical, partial/complete),eye position, pupils (size: big in CN III palsy, small in Horners, normal in myasthenia/myotonic dystrophy/CN III palsy).PMH: autoimmune conditions, CVS risk factors.Consider Horner’s syndrome: cough, haemoptysis, chest pain, smoking history, weight loss (Pancoasts tumour causing Horner’s syndrome), loss of sweating on face/arms/trunk, any trauma/surgery on neck, any pain in neck, any headache.Neuro Questions: sensory loss, headache, seizures, tremor, unsteadiness, etc.Consider Myotonic dystrophy: balding, cataracts, heart problems, lung problems, gut problems, diabetes, excessive daytime sleepiness.Triggers of myaesthenic crisis: infection, drugs (recent antibiotics, beta-blockers, calcium channel blockers.Double vision: is this worse at the end of the day.Timing questions: symptoms since when, sudden/gradual onset, intermittent/constant symptoms, getting worse, worse at the end of the day?.In station 5 you may be asked to assess a patient with eyelid drooping, double vision, weakness etc.
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