M2 ANATOMY

While on a hospital rotation you are caring for a patient who was admitted by the hematology and oncology team.  The patient is a nineteen-year-old man and was recently diagnosed with Hodgkin’s Lymphoma. During your morning rounding, you check in on the patient and perform an abbreviated physical exam. 

During your physical exam, you notice that the patient’s right upper eyelid droops slightly lower than his left upper eyelid. Focused questioning reveals that the patient has no knowledge of any congenital ptosis and has never been told that his right eyelid droops. You look more closely at his eyes and notice that in the dim light of the room you can readily appreciate that his right pupil is smaller than his left (anisocoria). When you shine a light into his eyes, both pupils constrict, but the pupil on the right exhibits a delay in dilation when the light source is removed. Even after the delay in dilation, the pupil on the right remains slightly smaller than the pupil on the left. You also notice that while the patient’s room is warm, he has a small amount of sweat on the left side of his face, but none on the right side.

Following your exam, you excuse yourself from the patient’s room, and go back to a conference room to review her medical history and admission notes. Nowhere in the notes do you find any history of neurologic or ophthalmologic pathology.