R Sathemma Short Case 1902102055
A 55 year old female patient came with Diminsion of View in Right Eye since 1 year
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CHIEF COMPLAINT
A 55 year old female patient came to opd with complaint of Diminison of View in Right Eye since 1 year
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic one years back then he developed Diminison of view in the Right Eye which was Insidious in nature and gradually progressing
HISTORY OF PAST ILLNESS
Has h/o Hypertension was on Amlokind (5mg+50mg) medication AT/OD
No H/o Asthama , TB ,DM
FAMILY HISTORY
No significant complaints in family history
TREATMENT HISTORY
SURGERIES : H/o Cataract surgery left eye 8 years back
PERSONAL HISTORY:-
Married
Appetite- Normal
Diet - Mixed
Bowel and bladder- Regular
No known allergies
Habits- NO HABITS
GENERAL EXAMINATION
pallor-No
Pedal edema-No
No clubbing of fingers ,cyanosis,icterus,lymphadenopathy
VITALS
Temperature-Afebrile
Pulse rate -78bpm
Bp-110/90mm of Hg
spo2-98%
SYSTEMIC EXAMINATION:
CVS
S1 &S2 heard
No thrills
No cardiac murmurs
RESPIRATORY SYSTEM
INSPECTION
Size and shape -bilaterally symmetrical
Position of trachea-central
Apical impulse-not seen
Chest expansion-symmetrical
PALPATION:
Trachea- midline
Chest movements- symmetrical
No intercoastal widening
PERCUSSION
No tenderness over chest wall
No added sounds
No pleural rub
Right Left
Supraclavicular R R
Infraavicular R R
Mammary R. R
Infra mammary Dull R
Axillary R R
Infra axillary R R
Suprascapular R R
Interscapular R R
Infrascapular R R
AUSCULTATION
Normal vesicular breath sounds heard
Right Left
Supraclavicular NVBS NVBS
Infraclavicular NVBS NVBS
Mammary NVBS NVBS
Axillary NVBS NVBS
Infra Axillary NVBS NVBS
Suprascapular NVBS NVBS
Interscapular NVBS NVBS
Infrascapular NVBS NVBS
ABDOMEN
INSPECTION
Shape of abdomen: Normal
Surface of abdomen has no scars ,dilated veins , visible peristalsis
PALPATION
Liver and spleen not palpable
PERCUSSION
Resonance sound is heard
AUSCULTATION
Bowel sounds are heard
CNS
Patient is conscious
Speech normal
No neck stiffness
Motor and sensory system- Normal
EYE EXAMINATION
LIDS LL Concretion LLConcretion
CONJUNCTIVA Muddy Muddy
CORNEA
AC NAD NAD
IRIS NCP NCP
PUPIL NSRL NSRL
LENS Brown to Pseudoplakia
Mature
On 11/7/2023
RIGHT EYE LEFT EYE
LIDS LL Concretion LLConcretion
PUPIL NSRL NSRL
LENS. BROWN TO Pseudophakia
MATURE
On 12/7/2023
RIGHT EYE LEFT EYE
LIDS LL Concretion LLConcretion
PUPIL NSRL NSRL
LENS BROWN TO Pseudophakia
MATURE
PROVISIONAL DIAGNOSIS
Right eye Brown to Mature
INVESTIGATIONS
