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Emergency Medicine

Answer 1
  1. Cerebral aneurysm. An acute third nerve palsy should raise concern of an intracerebral aneurysm, most commonly expansion of a posterior communicating artery aneurysm. If the diagnosis of subarachnoid hemorrhage is entertained, then a computed tomography scan (with lumbar puncture if the scan is negative) should be performed. A brain tumor presentation can include a third nerve palsy, although the duration of symptoms would typically be longer, and other findings would ordinarily be present. Horner’s syndrome—ptosis, myosis, and anhydrosis—should prompt a work-up for a thoracic or neck mass, carotid dissection, or another condition that can interrupt sympathetic innervation. Cavernous sinus thrombosis usually follows a facial or sinus infection. Although, this condition can include a third nerve palsy, a sixth nerve palsy is much more common. Although there can be many ocular presentations of multiple sclerosis, optic neuritis with pain and decreased visual acuity would be a more typical presentation.

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