Ejection Click and Ptosis

Work it one clue at a time. The diagnosis stays hidden until you reveal it.

Clue 1

A 54-year-old man admitted for alcohol withdrawal was noted to have subtle but critical physical findings. Other than nausea, he had no complaints. Examination revealed left-sided ptosis that worsened after sustained upward gaze. Cardiac auscultation detected an extra transient sound near S1, best heard over the base of the heart, along with a decrescendo diastolic murmur over Erb’s point.

Clue 2

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