Pupil sparing 3rd nerve palsy
A 45 year old female tailor by occupation came with
c/o headache with dragging sensation in the eyeballs since 3 days
Dropping of eyelid since 1 day
Double vision in the right eye since 1day
Vomitings since 3 days
HOPI: patient was apparently asymptomatic 1 month back.then she had diminision of vision for which she went to a ophthalmologist in nalgonda, they prescribed glasses for her eyesight. Then after using them for few days she got severe headache with dragging sensation in both the eyeballs. She went to a hospital in suryapet and was prescribed by pain killers.
Then next day she developed swelling of right eye, drooping of eyelid, double vision in right eye and vomitings since 3 days which was non bilious, non projectile
No h/o sudden onset weakness of limbs
No h/o any dizziness
Not a k/c/o DM, HTN, TB , ASTHMA, CVA, CAD
GENERAL EXAMINATION:
patient is c/c/c
No pallor, no icterus, cyanosis, clubbing,koilonychia lymphadenopathy.
VITALS:
Temperature: 98.6
Bp:130/90 mmhg
PR:56
RR: 20
Spo2: 99 on RA
Gcs:E4V5M6
CVS : S1 S2 heard
RS: BAE+
P/A: soft, non tender
CNS EXAMINATION:
Speech normal
Pupils normal
Cranial nerve -3
Left : normal
Right: lateral rectus+
Medial rectus -ve
Superior rectus -ve
Inferior rectus -ve
Sensory 6th intact
Other cranial nerves - intact
Tone : Rt Lt
UL Normal Normal
LL Normal Normal
Power: Rt Lt
UL 5/5 5/5
LL 5/5 5/5
Relfex:
Rt Lt
B - +2 +2
T - +2 +2
S- +2 +2
A - +2 +2
K - +2 +2
P- Flexor Flexor
neck stiffness -ve
Gait - normal
Investigations:
Diagnosis: pupil sparing 3rd nerve palsy
TREATMENT:
1. IVF - NS, RL @100ml/hr
2.INJ PAN 40mg IV/OD
3.INJ CIPLOX 200mg IV/BD
4.INJ METROGYL 100ml IV/TID
5.INJ ZOFER 4mg/IV/TID
6.INJ DICLOFENAC 75mg(3cc) IM/BD
7.VITALS MONITORING 4th hrly
8.INFORM SOS
13/5/22
S- no fresh complaints
O- right eye ptosis , mild conjuctival congestion
H/o lid swelling+, monocular diplopia, retropulsion+
Orbital movements:
rightt eye- abduction +
Left eye- all movements +
CN-3 no right lid elevation/medial rotation
Vitals:
Temp-afebrile
PR: 65
RR: 18
BP: 100/60
CVS-s1s2+
RS - BAE+
P/A- soft, non tender
A- 3rd CN palsy with pupillary sparing secondary to TOLOSA HUNT SYNDROME
P-
1. INJ METHYLPREDNISOLONE 1gm /IV OD IN 100ml NS
2.INJ PAN 40mg IV/OD
3VITALS MONITORING 4th hrly
4.INFORM SOS
14/5/22 day 3
S- no fresh complaints
O- right eye ptosis , chemosis resolved
lid swelling resolved, monocular diplopia, retropulsion+
Orbital movements:
rightt eye- abduction +
Elevation,depression,adduction,intorsion -absent
Left eye- all movements +
CN-3 no right lid elevation/medial rotation
Vitals:
Temp-afebrile
PR: 58
RR: 18
BP: 110/70
CVS-s1s2+
RS - BAE+
P/A- soft, non tender
A- 3rd CN palsy with pupillary sparing secondary to TOLOSA HUNT SYNDROME
P-
1. INJ METHYL PREDNISOLONE 1GM in 100 ml NS OD
2.INJ PAN 40mg IV/OD
3.VITALS MONITORING 4th hrly
4.INFORM SOS
15/5/22 day 4
S- no fresh complaints
O- right eye ptosis , chemosis resolved
lid swelling resolved
Ptosis +
Orbital movements:
rightt eye- abduction +
Elevation,depression,adduction,intorsion -absent
Left eye- all movements +
Vitals:
Temp-afebrile
PR: 64
RR: 18
BP: 160/80
CVS-s1s2+
RS - BAE+
P/A- soft, non tender
A- 3rd CN palsy with pupillary sparing secondary to TOLOSA HUNT SYNDROME
P-
1. INJ METHYL PREDNISOLONE 1GM in 100 ml NS OD
2.INJ PAN 40mg IV/OD
3.INJ HAI s/c acc to grbs
4.VITALS MONITORING 4th hrly
5.INFORM SOS
16/5/22 day 5
S- no fresh complaints
O- right eye ptosis , chemosis resolved
lid swelling resolved
Ptosis +
Orbital movements:
rightt eye- abduction +
Elevation,depression,adduction,intorsion -absent
Left eye- all movements +
Vitals:
Temp-afebrile
PR: 64
RR: 18
BP: 100/60
CVS-s1s2+
RS - BAE+
P/A- soft, non tender
A- 3rd CN palsy with pupillary sparing secondary to TOLOSA HUNT SYNDROME
P-
1. TAB METHYL PREDNISOLONE 1MG/KG PO/OD
2.TAB PAN 40mg PO/OD
3.INJ HAI s/c acc to grbs
4.VITALS MONITORING 4th hrly
5.INFORM SOS
