----- Original Message -----
From: "John Ryan"
Subject: Re: Isolated 6th nerve palsy
> CXR ? Not done. Granted she is a smoker but she has no pulmonary
sympotoms
> or signs. Is a CXR really the test most likely to indicate where to go
from
> here ? I see junior doctors do that sort of thing all the time and I cant
> help wondering if they are procrastinating and sending people for tests
> because they dont know whats wrong and hoping that when the results come
> back they wil have gone off duty and it will be up to someone else to sort
> out a management plan.
Couldn't agree more!
> I thought about a CT but felt that whatever the problem was, given the
> isolation of her signs, that it would be most likely quite isolated and
> maybe even small. Then I wondered about the need for investigation, was it
> routine, urgent or emergent ? I was concerned that given the headaches
> there migth be a vascular explanation for her symptoms and signs and
did'nt
> fancy hearing about 'this woman who went home yesterday'. Also the
anatomy
> throws up lots of potential nasty causes:
> So I bottled out and requested a MRI on the basis that this was the test
> most likely to give me a localised explanation if one existed.
And that is the way we think as emergency physicians. We try to aim for the
quick diagnosis, often at the expense of being exclusive or thorough. But
more importantly we're interested in the diagnoses that'll kill quickly. So
CXR will be less useful to us - sarcoidosis and chest tumours may be nasty,
but they're not going to cause death in the next few days - intracranial
aneurysms will.
> Isolated sixth nerve palsy from pontine infarct Acta Neurol Belg 2000
> Dec;100(4):246-7
>
> Isolated sixth nerve palsy: an uncommon presenting sign of multiple
> sclerosis. J Neurol 2000 Sep;247(9):701-4 Barr D, Kupersmith MJ, Turbin R,
> Bose S, Roth R.
>
> Painless abducens palsy disclosed by spontaneous dissection of the
> intracavernous internal carotid artery Ducrocq X, Lacour J, Anxionnat R,
> Marchal C, Bracard S, Vespignani H.Rev Neurol (Paris) 2000
May;156(5):520-2
But can this be described as "isolated"? It certainly isn't a painless
palsy, although it may be a discrete neurological lesion. MS won't explain
the headaches will it? I still think MR angiography is the way to go from an
EM point of view!
Adrian Fogarty
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