Rosh Emergency Medicine Practice Test

What physical examination finding would be expected in a patient presenting with dysphagia and double vision?

1. Ptosis with sustained upward gaze

2. Reflexes that increase with brief muscle activation

3. Relative afferent pupillary defect

4. Shiny, thickened areas of skin on the digits

The correct answer is: Ptosis with sustained upward gaze

In a patient presenting with dysphagia (difficulty swallowing) and double vision (diplopia), the finding of ptosis with sustained upward gaze is indicative of a neurological problem, specifically related to the cranial nerves involved in eye movement and possibly the neuromuscular junction. Ptosis refers to the drooping of one or both eyelids, and when combined with double vision and difficulty swallowing, it may suggest a condition such as myasthenia gravis. This autoimmune disorder affects the communication between nerves and muscles, leading to fluctuating muscle weakness. When the patient is asked to sustain an upward gaze, the muscles that control those movements might become exhausted quickly, leading to ptosis. The other options reflect different medical scenarios. Increased reflexes after brief muscle activation might indicate an upper motor neuron lesion, whereas a relative afferent pupillary defect would suggest a defect in the afferent pathway of vision, and the shiny, thickened areas of skin on the digits could indicate systemic sclerosis or another dermatological condition. Each of these is unrelated to the combination of dysphagia and diplopia, which is better explained by the neuromuscular involvement that causes ptosis in this context.