CC: right eye droop, double vision
HPI: 108 year old elven male with no PMH, presents to the clinic with complaint of right eye droop, double vision. Patient is an elite operative agent of [redacted], with frequent exposure to magical combat situations. he frequently uses teleportation magic in his daily work. 2 weeks ago, patient was [redacted] and had sudden onset intense headache and subsequent symptoms as described above. Symptoms have not improved since onset. he denies any other symptoms, including focal weakness, numbness, speech difficulty, coordination difficulty.
ROS: negative.
PMH/PSH: denies.
SH: denies tobacco, alcohol, illicit drug, illicit spell use
FH: no family history of aneurysms.
Allergies: NKDA
Meds: none.
Exam:
HEENT: bilateral clipped ears, well healed
Skin: multiple scars over the arms legs and torso of differing ages, well healed.
Neuro:
Cranial Nerves: Right pupil dilated with decreased reactivity, 5mm. Left pupil 3mm briskly reactive. Right eye extortion, elevation, adduction palsy. Right ptosis, moderate.
Assessment: 108 year old elven male with no PMH, presenting for first time evaluation of right pupil-involving cranial nerve III palsy, likely due to a right posterior communicating artery aneurysm from magical trauma
Plan:
-scrye angiography, with plan for elimination of aneurysm from circulation
-patient counseled on seeking immediate medical care with onset of similar symptoms in the future.
-patient counseled on dangers of abjuration and teleportation magic and aneurysm rupture.
