73yr F with diminision of vision.

A 73 years old female patient who is  an agricultural worker by profession from peddasuraru, came to casualty with c/o diminision of vision since 2 years.
 
History of present illness:

Patient was apparently asymptomatic, 2 years back when she developed diminision of vision in both eyes which is insidious in onset, gradually progressive. 

History of past illness:
Right eye Got operated with SICS  PCIOL
K/c/o -HTN,asthama
No H/o - TB,DM,CAD

Personal history:

 Diet : mixed
 Appetite : adequate 
 Bowel movements : regular
 Bladder movements : regular
 Sleep : distrubed
 Addictions : occasionally toddy.
 Allergies : no allergies

General examination :

Pallor : absent 
Icterus : absent
Cyanosis : absent
Clubbing : absent
Lymphadenopathy : absent
Pedal oedema: absent
 
                           Left eye 
                                Right eye

Vitals:
Temperature : 97.5°F
BP : 130/70 mmHg
PR : 85 bpm
RR : 14 com
SpO2 : 98%

Ophthalmic examinations:
 
                                  RE                       LE
VA  :                     CF- 1m                   6/60       
Eye lids :              normal                 normal
Conjunctiva :     early nasal pterygium           
Cornea :               normal                  normal
AC :                       NAD                       NAD
Pupil :                   NSRL                      NSRL
Lens :                IMSC Nsg-II        IMSC Nsg-II

Fundus examinations:

Disc :         normal in size,             normal in size,
                      Circular,                          circular,
      Well defined margins   well defined margins
CDR :         0.3 : 1                            0.4 : 1
Vessels :     attenuated                      normal
Macula  :        dull                                 dull

Systemic examinations:

1. CVS - S1, S2 heard.no murmur.
2. Respiratory system- normal vesicular breathe sounds (NVBS) heard.
3.CNS - NAD
4. Abdomen - soft, no organomegaly.

Provisional Diagnosis : 
both eyes, immature senile cataract (IMSC)

Investigations : 

HIV 1/2 rapid test reported on 21/02/2022
HBsAg rapid test reported on 21/02/2022

Treatment:

E/oint CIPLOX - BD
Tab. AMLOKIND -OD

Plan of care :  SICS , PCIOL.
 


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