Multiple cranial nerve palsy with normal MRI

A 49yr old male presented to the casuallty with
c/o headache -b/l frontal radiating to the back
A/w -blurring of vision in both eyes since 2 days
Giddiness on getting up from lying down position
Drooping of upper eyelid - on the rt with deviation of mouth to the right
Not a/w vomiting ,photophobia ,phonophobia,
Weakness of limbs,deviation of tongue,loc, bowel and bladder abnormalities
There is no drooling of saliva, difficulty in swallowing, hearing impairment, palpitations, loss of sensations of the face
K/c/o htn since 5 yrs on aten+amlodipine (50/5)good compliance as per pt.and attenders
K/c/o smoker since 10yrs 10bidis /day
K/c/o chronic occasional alcoholic 90ml whiskey with last binge 2 months back

O/E
General condition" conscious coherent
Moderately built and moderately nourished
No pallor ,icterus,
Clubbing+
Cyanosis of tongue +
PR-106/min
Bp-170/90mmhg
CVS -both S1 and S2 heard in all areas ,no murmurs
RS bae+ nvbs in all areas
P/a- soft ;non tender
Cns: hmf intact(orientation to time place person,speech memory)
Cranial nerves(positive findings)
3- pupils were constricted,not reacting to light on both sides
Ptosis of upper eyelid on the right
6-left lateral gaze palsy of the left eye
7-ptosis, deviation of mouth to the right ,
  Frowning, nasolabial crease, clenching of teeth present
8- no hearing loss,tinnitus
    Test for bppv- negative
9 to 12-nomal
Motor" normal tone ,power, all reflexes present
Sensory,: no deficit in face and all over the body

Gait-ataxia with prominent sway on the rt side
Nystagmus-present (horizontal with fast component towards the right side on lateral gaze)
No dysdydokinesia,pendular knee jerk,rebound phenomenon, finger nose,finger finger in ordination


Differential
Sudden onsent with constricted pupils- ich
Ptosis with deviation of mouth- Rt sided 7th nerve palsy
Ptosis,myosis- Horner's syndrome
Left lateral gaze palsy+ 7th nerve -lesion in the pons
(Probably pprf centre)
Investigations
Mri- focal chronic infarct in rt pons
       T2 flair, dwi- did not shows signs of acute lesion



On subsequent days ,
Pt had hypertensive urgency(bp >=180/110mmhg)
He was given telma h+ cilindipine (40/10)mg
And secondary causes of hypertension were evaluated
Ecg-LVH pattern
On usg he was found to have mild cmd differentiation loss of both kidneys with b/l grade 1 RPD changes revealing a h/o nsaid abuse for joint pains for 2 yrs
And intake of food rich in sodium and saturated fatty acids.

He was discharged with
Advice on lifestyle modification(diet+exercise)
T.telma+cilindipine(40/10) od
Prophylactic t.ecosprin 75mg +t.atorvas 40mg
And asked to follow up regarding his bp control


Theory:
In due course of evaluation, theory regarding the case was discussed with my senior and colleagues


The above picture contains the normal mechanism of horizontal gaze (rt.sided as per the patient)

The above picture(GUYTON textbook of physiology) is an illustration about the sympathetic control of pupils and the rationale for ? HORNER'S SYNDROME as the differential.

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