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Dr. Ateendra Jha
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Clinical Challenge-4

12 August 2020

A 55-year-old man with a history of hypertension and migraines is sent by his primary care provider to the emergency department for a spinal tap to rule out meningitis. He states that he has had a headache for approximately 3 days that came on gradually and is in his midlower forehead and nose area bilaterally. He also feels neck stiffness and subjective fever but never checked his temperature. He denies any vomiting or photophobia. When asked, he says that the pain is slightly worse on the left side. He does not think that it is a migraine, because previous migraines had never lasted this long and he had never felt feverish from a migraine before. His sister happens to be with him and mentions that yesterday his left eyelid was quite droopy, but today it is less so. 

Examination Neurologic exam is normal. See image of the patient's eyes. 

  • What does the image show? 

  • What should you do next?