42yr Female with left eye ptosis

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Case presentation:

A 42yr old Female who is a labourer by occupation presented with

 C/o Low backache since 1 week

Drooping of left eyelid since 3days

Headache since 3 days.

HOPI:

Patient was apparently asymptomatic 1 week back then she developed low back whi ch was gradually progressive and relieved on taking rest.

Then she developed drooping of left eyelid 3 days back which is sudden in onset no aggrevating and relieving factors. 

And developed  Headache 3 days back in the frontoparietal region, gradual onset and progressive in nature.

She had so severe headache since 2 days that she got up in mid night and had a cool water head wash and her headache was decreased and she slept off.

Headache is not associated with nausea, vomitings, photophobia,blurred vision. 

No H/o trauma, fever, neck stifness.

PAST HISTORY: Not a known case of Hypertension, Diabetes Mellitus, Asthma.

H/O burning micturation 10yrs back for which she was diagnosed with renal calculi in rt kidney (no documentation) and treated conservatively

H/O trauma to legs 20yrs back and took herbal medications .

No similar complaints in the past

PAST SURGICAL HISTORY:

H/O cataract surgery of Rt eye 7yrs back and Lt eye 3yrs 

PERSONAL HISTORY:

Appetite lost

Mixed diet

Sleep adequate

Addictions: Occasional alcoholic

FAMILY HISTORY: not relevant

ON EXAMINATION:

Pt is conscious coherent cooperative well orientated to time place person

Patient is moderately built and moderately nourished

Pallor is present

No icterus, cyanosis,clubbing,lymphadenopathy,odema

Vitals:

Afebrile

BP: 110/80 mm hg

PR : 80bpm

RR : 20cpm

SPO2 : 96% ON RA

GRBS: 112 mg%

SYSTEMIC EXAMINATION:

Cvs - s1, s2 heard, no murmurs

RS - BAE+, No added sounds

P/A - soft and non tender, Bowel sounds heard.

CNS - 1)HMF:

  patient conscious

  oriented to place/time/person

 2)CRANIAL NERVES-

All cranial nerves intact except 3rd nerve

3rd nerve: Loss of convergence

Left eye

Medial rectus, superior rectus and inferior rectus palsy

Both pupils dilated and non reactive to light

 MOTOR SYSTEM 

                                        Right             Left

Bulk:    inspection       Normal          Normal

             palpation.        Normal          Normal

Measurements  U/L   Equal on both sides

                          L/L   Equal on both sides

Tone:          

                         UL       Normal       Normal

                         LL       Normal         Normal

Power :

                      UL               5/5             5/5

                      LL              5/5             5/5

 

          

Reflexes: Present 

                  

SENSORY SYSTEM :could not be elicited 

Cerebellar function: Normal

No meningeal signs

                                    

Investigations:

CUE

HEMOGRAM

RFT

ECG

CHEST X RAY 

Diagnosis: ? 3rd nerve palsy secondary to sarcoidosis, tuberculosis, vasculitis

Treatment: 

INJ CEFTRIAXONE 1GM IV BD

INJ PANTOP 40MG IV BD

IVF 2 NS,1.NS @75ml /hr with OPTINEURON 

TAB NAPROXEN 250MG BD

Day 2

C/o passed stools 4 times

C/o headache (not subsided with medications)

INVESTIGATIONS:

HEMOGRAM

FUNDOSCOPY

MRI

Treatment:

INJ CEFTRIAXONE 1GM IV BD

INJ PANTOP 40MG IV BD

IVF 2 NS,1.NS WITH 1 AMP OPTINEURON

NEBULISATION WUTH SALBUTAMOL

TAB NAPROXEN 250MG BD

INJ PIPTAZ 2.25 GM IV QID

Day 3

Patient underwent sudden cardiac arrest.. 

Started CPR and intubated. Despite of all the efforts patient couldn't be revived. 

ECG shows flat electrical line.