case 2 42yr Female with left eye ptosis


This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 

Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome. 

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. 

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