60 YEARS OLD MALE WITH DIMINUTION OF VISION IN LEFT EYE

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centred online learning portfolio and your valuable inputs on comment box is welcome.

DATE OF ADMISSION : 21/02/2022

Chief complaint  : 
Diminution of vision in left Eye since 6 months

History of patient : 
Patient is suffering from Diminution of vision from past 6 months 
He is having blurred/improper vision since 6 months he is not able to see things properly.
Patient came to hospital for eye check up and he got to know he have "Cataract" in his left eye after been diagnosed by the Doctor.
Then he was suggested to get admitted in hospital and then he was prepared to undergo An Eye Surgery.

Past history :
No similar complaints in past 
No DM, TB, Asthma, Epilepsy 
Hypertension since 4 years
Personal history :
Appetite- Normal
Sleep- Adequate
Bowel and Bladder movements- Regular
Addictions- Patient used to consume alcohol twice or thrice weekly.
Occasional smoker. 

Family history :
Insignificant

Vitals :
Temp- 98.8 F
PR- 84 bpm
BP- 140/80 mmHg 
RR- 18 cpm
Spo2- 98% at RA

General Examination :
Patient is conscious, coherent and cooperative. 
No signs of Pallor, Icterus, Cyanosis, Clubbing,Lymphadenopathy or Edema.

INVESTIGATIONS :
Systemic: 
CBP, ESR, RBS

Occular:  

IOP Calculation by Tonometry
IOL Power Calculation
A scan Ultrasonography

PROVISIONAL DIAGNOSIS :
Unilateral Immature Senile Cataract.


Comments

Post a Comment

Popular posts from this blog

A 19 year old male with fever and severe body pain

Sir this case was taken on 23rd September A 19yr old male patient came to the opd with chief complaints of fever Since 1 week. HOPI:- Patient was Apparently asymptomatic 1 week back then he developed fever with chills which is high grade ,sudden in onset & associated with body pains .Relieved on medication. 2 days back he was taken to outside hospital there his platelet count was 1,29,000 cells/cumm, yesterday they were 1,32,000cells/cumm.Today they were 98,000cells/ cumm. No h/o Loose stools, vomitings, No h/o Hematuria, dark stools. No h/o pain abdomen,giddiness. PAST HISTORY:- Not a k/c/o HTN,DM, Thyroid, Epilepsy. PERSONAL HISTORY:- diet- mixed Appetite- normal Sleep- adequate Bowel and bladder movement- normal GENERAL EXAMINATION:- Patient was conscious, coherent, cooperative,well oriented to time place and person. Moderately built & moderately nourished. No pallor,Icterus,cyanosis, lymphadenopathy, clubbing. BP -90/60mmhg PR -84 RR -14cpm Spo2 -99 Temp:-99.5 F CVS- S1 S2
Read more

A 27 yr old Male with fever and Weakness

Image
A 27 years old male patient who is preparing for govt. job is also an agriculture worker , came to the opd with the complaints of  •fever since 15 days  •generalized weakness since 1 month. HOPI: patient was apparently asymptomatic 1 month back,then he developed generalized weakness and dizziness. He visited some MBBS doctor for the same complaints,was given some medications and was advised to visit a hospital. • H/o fever since 15 days. On and off.  Low grade. Not a/w chills, rigor. No h/o muscle pain. H/o loss of weight of 10 kgs in 6 months  He does agricultural work for 6 hours in a day and then he prepares for govt. job at night. H/o decreased intake of food and inadequate sleep since 1 month. No h/o abdominal problem. No h/o cold and cough. No h/o burning micturition. No h/o numbness,tingling sensation • past history: No similar complaints in past. Not a k/c/o TB,asthma,htn,DM,CAD,epilepsy. PERSONAL HISTORY: Appetite : less Sleep: inadequate Diet: mixed B/b : regular Addiction
Read more