Make a case sheet for a patient with lat rectus palsy presented with double vision for 4 days and headache 4days back for 2 days
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I now have all the clinical content needed. Here is the complete case sheet:
OPHTHALMIC / NEUROLOGY CASE SHEET
PATIENT IDENTIFICATION
| Field | Details |
|---|---|
| Name | Mr. Ramesh Kumar |
| Age / Sex | 52 years / Male |
| Date of Admission | 21 July 2026 |
| IP No. | ________ |
| Bed No. | ________ |
| Occupation | Farmer |
| Address | ________ |
| Referred by | ________ |
| Ward | Ophthalmology / Neurology |
CHIEF COMPLAINTS
- Horizontal double vision - 4 days
- Headache - 4 days (resolved 2 days back, lasted 2 days)
HISTORY OF PRESENT ILLNESS
Patient Mr. Ramesh Kumar, a 52-year-old male, presented with a 4-day history of binocular horizontal diplopia. He reports the double vision is worse when gazing to the left side (i.e., toward the side of the affected eye) and at distance fixation. The images are side-by-side (horizontal separation), and the outer false image disappears on covering the affected eye. He adopts a compensatory head turn toward the affected side to reduce the diplopia.
Diplopia was preceded by diffuse global headache of moderate intensity that began simultaneously, lasting for 2 days, and has since resolved. He denies any associated nausea, vomiting, or photophobia during the headache episode.
He denies:
- Ptosis or drooping of eyelid
- Vertical diplopia
- Facial pain or numbness
- Facial weakness
- Hearing loss or tinnitus
- Difficulty swallowing or phonation
- Limb weakness or sensory disturbance
- History of trauma
- Ear discharge or recent ear infection
- Recent viral illness or vaccination
- Any new medications
PAST HISTORY
| Diabetes Mellitus | Yes - diagnosed 8 years ago, on oral hypoglycemics (Metformin 500 mg BD) - poorly controlled (HbA1c not recently checked) |
| Hypertension | Yes - diagnosed 5 years ago, on Amlodipine 5 mg OD |
| Coronary Artery Disease | No |
| Tuberculosis | No |
| Previous surgeries | No |
| Previous similar episode | No |
FAMILY HISTORY
- No family history of similar illness
- No family history of intracranial tumors or vascular disease
PERSONAL HISTORY
| Diet | Mixed (non-vegetarian) |
| Appetite | Normal |
| Sleep | Disturbed (due to headache onset) |
| Bowel/Bladder | Regular |
| Addiction | Occasional tobacco (beedi smoking) - 10 pack-year history |
| Marital Status | Married |
GENERAL PHYSICAL EXAMINATION
| Parameter | Finding |
|---|---|
| General appearance | Alert, oriented, cooperative, in no acute distress |
| Built / Nourishment | Moderately built, adequately nourished |
| Pallor | Absent |
| Icterus | Absent |
| Cyanosis | Absent |
| Clubbing | Absent |
| Lymphadenopathy | Absent |
| Edema | Absent |
| Pulse | 82/min, regular, good volume |
| Blood Pressure | 148/90 mmHg (right arm, sitting) |
| Temperature | 98.6°F (afebrile) |
| Respiratory Rate | 18/min |
| SpO2 | 98% on room air |
| Height / Weight | 168 cm / 74 kg |
| BMI | 26.2 kg/m² |
OPHTHALMIC EXAMINATION
Visual Acuity
| Right Eye (RE) | Left Eye (LE) | |
|---|---|---|
| Unaided | 6/9 | 6/6 |
| Best corrected | 6/6 (with +1.00 DS) | 6/6 |
| Near vision | N6 | N6 |
External Examination
| Finding | RE | LE |
|---|---|---|
| Lids | Normal | Normal |
| Ptosis | Absent | Absent |
| Proptosis | Absent | Absent |
| Conjunctiva | Normal | Normal |
| Cornea | Clear | Clear |
| Pupil (size) | 4 mm | 4 mm |
| Pupil (shape) | Round | Round |
| Light reflex (direct) | Present | Present |
| Light reflex (consensual) | Present | Present |
| RAPD | Absent | Absent |
| Anterior chamber | Deep, quiet | Deep, quiet |
| Iris | Normal | Normal |
| Lens | Early nuclear sclerosis | Clear |
Ocular Motility (Cover/Uncover, Prism Cover Test)
| Gaze Direction | Deviation | Finding |
|---|---|---|
| Primary position | Esotropia ~15 prism diopters | Left eye deviated medially |
| Gaze to the LEFT | Deviation increases | Marked underaction of LEFT lateral rectus |
| Gaze to the RIGHT | Near-normal alignment | Overaction of left medial rectus (secondary) |
| Vertical gaze (up/down) | Orthophoric | No vertical deviation |
Ductions:
- Left eye: Restricted abduction - unable to cross midline to the left
- Left eye: Adduction, elevation, depression - full
- Right eye: Full ductions in all directions
Head posture: Patient adopts a left-face turn to reduce diplopia
Diplopia charting: Horizontal uncrossed diplopia, maximal on left gaze and at distance fixation; the outer (left) image disappears on covering the left eye - consistent with left lateral rectus (CN VI) palsy
Slit Lamp Biomicroscopy
| Structure | RE | LE |
|---|---|---|
| Cornea | Clear | Clear |
| AC depth | Deep | Deep |
| Lens | Early NS grade 1 | Clear |
| Vitreous | Clear | Clear |
Fundus Examination (Dilated, indirect ophthalmoscopy)
| Finding | RE | LE |
|---|---|---|
| Disc | Pink, flat, cup:disc = 0.3 | Pink, flat (papilledema absent) |
| Vessels | Arteriovenous ratio 2:3 | A:V ratio 2:3 |
| Macula | Foveal reflex present | Foveal reflex present |
| Periphery | Normal | Normal |
Note: No papilledema seen - argues against raised intracranial pressure as etiology, but does not exclude it entirely in early cases.
Corneal Sensation
| RE | LE | |
|---|---|---|
| Sensation | Normal | Normal |
(Important to check - diminished corneal sensation suggests vestibular schwannoma/CPA lesion at pontomedullary junction, as per Kanski's Clinical Ophthalmology)
SYSTEMIC (NEUROLOGICAL) EXAMINATION
Higher Mental Functions
- Oriented to time, place, and person
- Speech: Normal
- Memory: Intact
Cranial Nerve Examination
| Nerve | Findings |
|---|---|
| CN I (Olfactory) | Not tested formally |
| CN II (Optic) | VA as above; fields grossly full; fundus as above |
| CN III (Oculomotor) | Intact - no ptosis, pupil sparing, full elevation/depression/adduction |
| CN IV (Trochlear) | Intact - no hypertropia, no excyclotorsion |
| CN VI (Abducens) | PALSY LEFT SIDE - restricted abduction, esotropia in primary position |
| CN V (Trigeminal) | Sensation intact V1/V2/V3; corneal reflex present bilaterally; no facial pain |
| CN VII (Facial) | Intact bilaterally - no facial weakness |
| CN VIII (Vestibulocochlear) | Hearing intact bilaterally (finger rub test) |
| CN IX/X | Intact - normal gag, palate elevates symmetrically |
| CN XI | Sternocleidomastoid and trapezius - normal |
| CN XII | Tongue protrudes in midline |
Motor System
- Tone: Normal in all four limbs
- Power: 5/5 in all four limbs
- Reflexes: Normal (2+) bilaterally, no clonus
- Plantar: Flexor bilaterally
Sensory System
- Pain, temperature, touch, vibration, proprioception - intact
Cerebellar Signs
- Finger-nose, heel-shin - normal
- Romberg's test: Negative
- Gait: Normal
Meningeal Signs
- Neck stiffness: Absent
- Kernig's sign: Negative
- Brudzinski's sign: Negative
SUMMARY
A 52-year-old male with known diabetes mellitus (poorly controlled) and hypertension presenting with a 4-day history of horizontal binocular diplopia with esotropia in primary position, restricted left eye abduction, and compensatory left face turn, consistent with left lateral rectus (CN VI / Abducens nerve) palsy. Associated history of headache for 2 days at onset (now resolved). Fundus shows no papilledema. No other cranial nerve involvement. No signs of meningism, raised ICP, or long-tract findings.
DIFFERENTIAL DIAGNOSES
| Priority | Diagnosis | Reasoning |
|---|---|---|
| 1st (Most likely) | Microvascular (Ischemic) CN VI palsy | Poorly controlled DM + HTN in a middle-aged male; pain near eye at onset; isolated palsy; no other neurological features. Up to 60% of isolated CN VI palsies in older adults are microvascular (Kanski's). |
| 2nd | Raised intracranial pressure | Headache at onset + CN VI palsy = classic "false localizing sign." Needs urgent neuroimaging. (Harrison's 22E; Kanski's) |
| 3rd | Cavernous sinus pathology (thrombosis, tumor, aneurysm, Tolosa-Hunt) | Check for involvement of CN III, IV, V1, sympathetic - currently absent |
| 4th | Petrous apex lesion / Gradenigo's syndrome | Facial pain + diplopia + ear infection; no ear symptoms here but must consider |
| 5th | Brainstem lesion (pontine infarct/tumor) | Nuclear CN VI lesion would cause horizontal gaze palsy + ipsilateral LMN CN VII palsy - absent here |
| 6th | Meningitis / Carcinomatous meningitis | No fever, no meningism; but LP may be needed if imaging inconclusive |
| 7th | Myasthenia gravis | Fatigable diplopia, no fixed restriction; test with ice pack / Tensilon if suspected |
INVESTIGATIONS ORDERED
Urgent
| Investigation | Reason |
|---|---|
| MRI Brain with contrast + MRA | Rule out brainstem infarct, cavernous sinus lesion, skull base tumor, raised ICP |
| Blood glucose (fasting + postprandial) | Confirm microvascular etiology |
| HbA1c | Assess glycemic control |
| Lipid profile | Vascular risk stratification |
| Complete blood count | Infection, anemia |
| Renal function tests | Diabetes complications; contrast safety |
| ESR / CRP | Inflammatory/infective cause |
Additional (if indicated)
| Investigation | Indication |
|---|---|
| Lumbar puncture (CSF analysis, opening pressure) | If raised ICP suspected, meningitis, carcinomatous meningitis |
| MR Venography | To rule out cerebral venous sinus thrombosis |
| Chest X-ray | Sarcoidosis, TB, primary malignancy |
| ANA, ANCA | Vasculitis |
| ACE levels | Sarcoidosis |
| Edrophonium (Tensilon) test / Acetylcholine receptor antibodies | If myasthenia gravis suspected |
| HbA1c (if not recent) | Already listed |
| BP monitoring | Hypertension control |
| Thyroid function tests | Thyroid orbitopathy can restrict lateral rectus (but typically restriction, not palsy) |
| Hess chart / Lees screen | Formal documentation of motility deficit |
| Orthoptic assessment | Measurement of deviation |
MANAGEMENT PLAN
Immediate
- Occlusion therapy - Patching one eye (monocular occlusion with eye patch or frosted lens) to relieve diplopia immediately
- Temporary Fresnel prism - Base-out prism on spectacles for symptomatic relief while awaiting recovery
- Urgent neuroimaging (MRI brain + orbits + cavernous sinus with contrast and MRA)
- Glycemic control - Optimize antidiabetic regimen; involve endocrinology if needed
- BP control - Optimize antihypertensives; target <130/80 mmHg
Medical
- Treat underlying cause (if identified on investigations)
- Vitamin B12 supplementation (if deficient; relevant to nerve recovery)
- Statin therapy for dyslipidemia (if present)
- Low-dose aspirin (if microvascular ischemic etiology confirmed)
Follow-up
- Reassess every 4-6 weeks for spontaneous recovery
- Up to 90% of microvascular CN VI palsies resolve spontaneously over weeks to several months (Kanski's Clinical Ophthalmology, 10th ed.)
- If no improvement at 3 months - re-investigate for occult etiology (chordoma, carcinomatous meningitis, carotid-cavernous fistula, myasthenia gravis) (Harrison's 22E)
Surgical (if no recovery by 6-12 months)
- Partial palsy: Medial rectus recession + lateral rectus resection (ipsilateral eye)
- Complete palsy: Vertical rectus muscle transposition (superior + inferior recti transposed adjacent to lateral rectus) + ipsilateral medial rectus weakening ± botulinum toxin injection ("toxin transposition")
- Permanent prism in spectacles for mild residual deviation
PROGNOSIS
- Good if microvascular etiology - most cases resolve within 2-3 months
- Prognosis depends on the underlying cause
- Regular follow-up mandatory; re-evaluate if no improvement at 3 months
PROVISIONAL DIAGNOSIS
Left Lateral Rectus Palsy (Left CN VI / Abducens Nerve Palsy) - likely microvascular, secondary to poorly controlled Diabetes Mellitus and Hypertension
(Raised intracranial pressure and other structural causes to be excluded by neuroimaging)
CONSULTANT'S SIGNATURE
Dr. ___________________
Department of Ophthalmology / Neurology
Date: 21/07/2026
References: Harrison's Principles of Internal Medicine 22E (2025, McGraw Hill) | Kanski's Clinical Ophthalmology: A Systematic Approach, 10th Ed. | Adams and Victor's Principles of Neurology, 12th Ed.
This case sheet is based on a 52-year-old male with the classical presentation of an isolated CN VI (abducens/lateral rectus) palsy. Key clinical points incorporated from the textbooks:
- The sixth nerve innervates only the lateral rectus; a palsy produces horizontal diplopia worse on ipsilateral gaze and at distance (Harrison's 22E)
- The abducens nerve's long intracranial course makes it vulnerable at multiple levels - brainstem, basilar cistern, petrous apex, cavernous sinus
- Microvascular disease (DM, HTN) is the most common cause in older adults (up to 60%), with spontaneous recovery in up to 90% of cases (Kanski's, 10th ed.)
- Headache with CN VI palsy must raise suspicion for raised ICP as a false localizing sign - this requires urgent neuroimaging (Adams & Victor; Harrison's)
- Gradenigo's syndrome (petrous apex lesion - facial pain + diplopia) and cavernous sinus pathology are important differentials (Adams & Victor, 12th ed.)
In this case diplopia will. Be
It looks like your message got cut off! Could you complete the question?
For example, were you asking:
- "Diplopia will be homonymous or crossed?"
- "Diplopia will be worse in which direction of gaze?"
- "Diplopia will be horizontal or vertical?"
- "Diplopia will be relieved by which head posture?"
Please complete your question and I'll answer right away!
I mean uniocular or binocular
In lateral rectus (CN VI) palsy, the diplopia is binocular.
Here is why:
Binocular diplopia means the double vision arises because the two eyes are misaligned - each eye on its own sees a single image, but together they produce two images because they are not pointing at the same object. Covering either eye makes the diplopia disappear immediately.
In lateral rectus palsy:
- The affected eye cannot fully abduct
- This causes a misalignment (esotropia) between the two eyes
- The two eyes project slightly different images onto non-corresponding retinal points, producing horizontal, uncrossed (homonymous) diplopia
- The separation is maximum on gaze toward the side of the palsy and at distance fixation
Uniocular diplopia (monocular diplopia) - double vision that persists even after covering the other eye - has a completely different cause (refractive errors, corneal irregularity, lens opacity, retinal pathology, or functional/psychogenic origin). It has nothing to do with extraocular muscle palsy.
Quick rule:
- Diplopia from any cranial nerve palsy (CN III, IV, VI) = always binocular
- Diplopia from ocular media / retinal / cortical causes = can be uniocular
So in your case sheet, the diplopia is definitively binocular, and it resolves on covering either eye - a key clinical point to document during examination.
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