60yr F DM+ HTN+ on irregular treatment c/c. pain L side of head x 5days ptosis. x 5days pupils both normal size, reacting to light neurological exam NAD except B/L ankle absent. Speech & other HMF normal Sensory NAD Dx & Rx please.

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Left 3rd berve palsy with sparing pupil. Is she diabetic.Absent ankle jerk at the age of 60yrs abnormal.If she is diabetic only one diagnosis Diabetic PPN with Mononeuritis affecting the left 3rd nerve.Pt is hypertensive, no mention about the DM state.If she is not diabetic still the functional diagnosis is the same ie mononeuritis lt 3rd with Ppn & check for the cause like vasculitis, Sarcoidosis

Diagnodis Diabetic 3rd netve palsy with large fiber peripheral neuropathy
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Bilateral ankle absence Ptosis pain lt side of headache are sign of peripheral neuropathy in diabetic patient . Normal pupil indicate normal intraocular pressure still measure IOP &.Examine for Blood pressure

Lacunar Stroke, diabetic neuropathy, pcom aneurysm, are d/d Also rule out myasthenia gravis for sure by history examination and investigation...

Rule out pcom aneurysm with CTA

What pcom will do
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Ptosis left Eye

Diabetic peripheral neuropathy with high possibility of ischemic third nerve palsy. Look of pupillary reaction

Pupillary reaction is spared in diabetic /ischemic palsy
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Any other muscle supplied by 3 Rd n affected pupillary size & reaction n , open the eyelid & check if congugate movements are affected

What about other external occular muscles & congugate movements

Conjugate movements can not be tested. Lateral movement of eye present
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MRI pontine region & vep . Internuclear opthalmoplegia looks a likely possibility.

@Dr. Manorama Rajan

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