DATE OF CONSULTATION: MM/DD/YYYY
HISTORY OF PRESENT ILLNESS: The patient is a pleasant (XX)-year-old Hispanic male who was in his usual state of health until he developed ptosis of his left eyelid and a cranial nerve III palsy. He has had diplopia. He has been evaluated by Oculoplastics, Neurosurgery, and Neurology. He had an MRI of the brain, which had some abnormalities, and this was followed by an MRA, which showed no evidence of a vascular flow problem. He has been given a diagnosis of Tolosa-Hunt syndrome. He has been placed on intravenous steroids as therapy for this. Infectious Disease consultation was requested for evaluation from an infection standpoint.
PAST MEDICAL HISTORY: The patient denies any past medical history.
PAST SURGICAL HISTORY: The patient denies any past surgical history.
MEDICATIONS: Protonix, Zofran, acetaminophen, and lorazepam.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient does not drink or smoke. He lives at home with his wife and two children, all of whom are well at this time. There has been no recent travel.
REVIEW OF SYSTEMS: No fevers. Positive chills episodically. No diarrhea. Positive nausea. No skin rash.
PHYSICAL EXAMINATION: The patient is an awake, alert, oriented male currently in no acute distress. Temperature is 98.2, and there have been no febrile spikes since the patient has been hospitalized. Pulse 64, respirations 18, and blood pressure 102/60. Weight is 67.2 kilos. Neck is supple. Mucous membranes are pink and moist. Sclerae are nonicteric. The left eye is notable for complete ptosis. The patient has some double vision when the eyelid is retracted. Conjunctivae are without injection, however. No anterior or posterior cervical adenopathy. No thyromegaly. No supraclavicular, axillary or epitrochlear adenopathy. Lung fields are clear to auscultation. No rales, rhonchi or wheeze. Heart has a regular rate and rhythm. No murmur, rub or gallop. Abdomen is soft and nontender. Positive bowel sounds diffusely. No hepatosplenomegaly. No guarding or rigidity of the abdomen. No abdominal tenderness. GU and rectal exams were deferred. Extremities with no palmar or plantar rash. The patient has a wart overlying the proximal interphalangeal joint on the fourth digit of the right hand. Nail beds are pink. Extremities without gross deformities. The skin is without rash.
DIAGNOSTIC DATA: The patient has had a CT, MRI, and MRA of the brain. MRI of the brain was remarkable for normal study. MRA was remarkable for normal study as well. CT scan of the head without contrast showed no evidence of masses. CT scan of the orbits was without abnormality. Chest x-ray performed was without abnormality.
LABORATORY DATA: White count 5.6. H&H are 14.2 and 41.6. Platelet count 356. PT/PTT are 11.4 and 31.2. Serum sodium 140, potassium 4.1, chloride 102, CO2 of 28. BUN and creatinine are 11 and 0.9. AST and ALT are 13 and 39. Lyme serologies as well as ACE level are pending at this time. The patient underwent LP and spinal fluid was without any white cells. Normal protein was evident. Sedimentation rate is 33. C-reactive protein is 0.18.
IMPRESSION:
1. A patient with third nerve palsy and left eye ptosis with diagnosis of Tolosa-Hunt syndrome.
2. No obvious sign of infection origin at this time.
3. Would have to rule out Lyme disease, however.
4. No obvious evidence of parasitic infection.
RECOMMENDATIONS:
1. We will check stool for ova and parasites.
2. Consider treating the patient empirically with a round of albendazole.
3. We will check Lyme, Western blot, and MHA-TP for indirect measure of Lyme disease. If these are positive, the patient would require intravenous antibiotics.
