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  This patient has complete ptosis of the right eye . When the eye lid is pulled up, it's seen that the eye is deviated outward and downward . Those two findings indicate that this is a third nerve palsy. Pupils of both eyes are equal. Pupil involvement (Fixed dilated pupil) is seen if the third nerve is compressed, because the parasympathetic fibers travel on the surface of the nerve. Conversely in non-compressive (Medical) third nerve palsies the pupil is spared . So this patient has right medical third nerve palsy. Lesions in various places can give rise to different presentations. For example..     Brain stem - The 6th nerve and other long tracts are close-by. So they will have involvement of either of those.     Cavernous sinus - A lot of structures pass adjacent to the nerve. So they will be involved. Now since none of those are affected, the lesion is probably in the nerve itself.  Common causes are diabetes and hypertension. Any other condition which causes mono-neuritis ca

 Regarding ACEI 1. Beneficial in DM nephropathy (T) 2. Beneficial in acute MI (T)     Particularly in anterior MI and in those who develop heart failure. 3. Causes angioedema (T) 4. Causes hyperkalemia (T)     And hyponatremia. Always monitor K+ in patients with renal diseases. 5. Increases S.Cr (T)     ACEI reduces the GFR and causes a mild increase in S.Cr. ACEI can also preciptate acute renal failure in patients with B/L Renal artery stenosis.'

Which of the following would indicate the possibility of non-diabetic kidney disease in a patient with DM? 1. Absence of retinopathy (T)     However 30% of patients with nephropathy have no retinopathy. But if a patient has no retinopathy always consider the possibility of a non-diabetic renal diseases. 2. Short duration of DM (T)     However, at the time of diagnosis of T2DM, patients may have early nephropathy. 3. Dysmorphic RBC (T)     RBC may be present in DM nephropathy, but not dysmorphic ones. 4. Rapid decline of S.Cr (T)     In DM the decline is gradual. It will be a stright line if the 1/S.Cr is plotted against time. 5. 3+ Proteinuria (F)     DM can cause nephrotic syndrome.

  Which of the following are risk factors for the progression of diabetic retinopathy? 1. Hypertension (T) 2. Smoking (T) 3. Pregnancy (T)          Pregnant patient with pre-existing DM should be closely monitored to detect worsening of retinopathy. 4. Statins (F) 5. Vigorous exercise (?T)     Vigorous exercise can precipitate haemorrhages in patients with proliferative retinopathy. 

  MCQ Corner - T/F Which of the following can cause acute painless loss of vision in a patient with DM? 1. Vitreous haemorrhage (T)     Seen in DM. Acute. Painless 2. Central retinal artery occlusion (T)     Seen in DM. Acute. Painless 3. Retinal detachment (T)      Seen in DM. Acute. Painless 4. Cataract (F)      Seen in DM. Chronic. Painless 5. Acute angle closure glaucoma (F)     Not associated with DM. Painful. Acute.

  This female patient with a past history of papillary carcinoma of thyroid presented with SOB and lower limb edema for 1 week. She has a massive pericardial effusion, which is probably due to the recurrence and metastasis of the tumor.

  This patient presented with SOB and fever for 2 days. He has varicella-zoster infection with possible pneumonitis, which is a serious complication.

  This elderly patient with long-standing diabetes presented with faintishness. What is the ECG diagnosis? He has inferior STEMI with complete heart block.