45 year old with pupil sparing 3rd nerve palsy

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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