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.
Right eye
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
Appetite : adequate
Bowel movements : regular
Bladder movements : regular
Sleep : distrubed
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
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.