Case Presentation A 15 year old girl came to the Emergency Room because of double vision. This started the week before and at first was intermittent but is now persistent. She sees the two objects side-to-side, and the separation is greatest when she looks to the left. She has had no other problem with her vision. However, for the last month, she has been having progressively worsening headaches. These are diffuse, tend to be maximal first thing in the morning, and worsen when she lies down. She has occasionally been woken up by headaches. She has had no nausea or vomiting. There have not been sensory changes, weakness, change in her coordination, or cognitive changes. She's had no ptosis, dysarthria, dysphagia, tinnitus, or hearing loss. She has not had any head injuries or seizures. This has never happened before, and she has no history of prior headaches. On examination, her weight is 82 kg and blood pressure 140/78. Mental status was normal. On cranial nerve examination, pupils equally reacted from 4.5 to 3.0 mm. She was sligtly photophobic and her fundi were difficult to see well. Visual fields were full to confrontation in each eye. She had limited abduction of her left eye. There was no ptosis. The rest of her cranial nerves were normal. She had normal muscle bulk, tone, and strength. Fine finger movements, deep tendon reflexes, finger-nose-finger testing, gait, and tandem gait were normal. Her toes went down bilaterally. Sensation was intact to detailed testing. Past Medical History- Her past history is positive only for moderate obesity and acne. Her only medications are tetracycline and ibuprofen. Family History- Negative. No one gets headaches. Social History- She is a B student and does not smoke or use drugs or alcohol. She is not sexually active. Review of Systems- Negative	Blood Tests Albumin and Protein Alpha-Feto Protein Ammonia Anti-AcetylCholine Receptor Antibody Titers Antiepileptic Drug Levels Anti-Nuclear Antibodies Anti-Streptococcal Titers Arterial Blood Gas Arterial Lactate, Pyruvate Biotinidase Assay Calcium Carnitine CBC with Differential Cholesterol Copper CPK Electrolytes Erythrocyte Sedimentation Rate FISH for Prader Willi, Angelman Syndromes FTA Glucose HIV Testing (Western Blot) Karyotype Lead Liver Function Tests Lysosomal Enzymes Magnesium PCR for Dystrophin Gene PCR for Fragile X Mutation PCR for SMN and NAIP Genes PCRs - Other Specific Tests Plasma Amino Acids Serum Immunoglobulin Levels Thyroid Function Tests VDRL Very Long Chain Fatty Acids Vitamin E Level Urine Studies 24 Hour Urinary Copper 24 Hour Urine Heavy Metals Reducing Substances Urinalysis Urine Amino Acids Urine Catecholamines Urine Mucopolysaccharides Urine Organic Acids Urine Protoporphyrins Urine Sulfites Urine Toxicology Screen CSF Studies AFB Staining and Culture Amino Acids Bacterial Culture Cell Counts Cryptococcal Antigen Cytology FTA Glucose and Protein Gram Stain IgG Index Lactate, Pyruvate Myelin Basic Protein Oligoclonal Bands Opening Pressure Tissue Studies Bone Marrow Biopsy Muscle Biopsy: Dystrophin Immunostaining Muscle Biopsy: Mitochondrial Enzymes Muscle Biopsy: Pathology Skin Biopsy for Fibroblasts Western Blot for Dystrophin Imaging Studies Abdominal CT Brain MR Angiogram Brain MRI Brain MR Venogram Carotid Doppler Catheter Angiogram Chest CT Echocardiogram Head CT without contrast Head CT with and without Contrast Head Ultrasound Orbital CT Spine MRI Electrophysiology Studies Brainstem Auditory Evoked Responses EEG EKG EMG, Nerve Conduction Velocities Sleep Studies Somatosensory Evoked Responses Visual Evoked Responses Specialized Studies Referral to Ophthalmology Wood's Lamp Throat Culture
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