60Y/ F CAME WITH C/O DECREASED OF VISION IN LEFT EYE SINCE 2 MONTHS H/O WATERING AND ITCHING SINCE 10DAYS

This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan
The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 

C/O DECREASED OF VISION IN LEFT EYE SINC 2 MONTHS

H/O WATERING AND ITCHING SINCE 10DAYS

HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC 2 MONTHS AGO THEN HE DEVELOPED DOV IN LEFT EYE WHICH WAS INSIDIOUS IN ONSET GRADUALLY PROGRESSIVE

NO H/O PAIN AND TRAUMA TO THE EYE

PAST HISTORY

K/C/O DIABETES SINCE 16 YEARS , ON GLIMI M1

N/K/C/O HTN, THYROID DISORDERS , EPILEPSY

PERSONAL HISTORY:

DIET:MIXED

SLEEP:ADEQUATE

BOWEL AND BLADDER:REGULAR

ADDICTIONS:NO

APPETITE:NORMAL

GENERAL EXAMINATION:

PATIENT IS CONSCIOUS,COHERENT,COOPERATIVE,WELL ORIENTED TO TIME,PLACE AND PERSON.

NO PALLOR,ICTERUS CYANOSIS,CLUBING,LYMPHADENOPATHY,EDEMA.

VITALS:

TEMPERATURE:98.6

BP:140/70 MM HG

PR:80 BPM

RR:18 CPM

SYSTEMIC EXAMINATION:

CVS:S1,S2 HEARD NO MURMURS.

RS:BAE +,NO MURMURS

PER ABDOMEN:SOFT,NON TENDER,NO ORGANOMEGALY

CNS:NO FOCAL NEUROLOGICAL DEFICITS.

TRANSFER NOTES

TRANSFERRED FROM OPHTHALMOLOGY TO GM I/V/O HIGH BLOOD SUGARS

INVESTIGATIONS:

Anti HCV Antibodies - RAPID 24-01-2024 05:37:PM Non Reactive

 HBsAg-RAPID 24-01-2024 05:37:PM Negative

POST LUNCH BLOOD SUGAR 25-01-2024 06:30:PM 345 mg/dl

 HbA1C - 7.5%

 FBS- 249 MG/DL


DIAGNOSIS:

LEFT IMMATURE SENILE CATARACT

DIABETES MELLITUS TYPE 2

TREATMENT:

TAB GLIMI MV1 PO OD

TAB GLIMI M1 PO BD

TAB NEUROKIND PO OD

TAB PREGABA NT 75/10 HS

Comments

Post a Comment

Popular posts from this blog

MY INTERNSHIP JOURNEY IN GENERAL MEDICINE.

Image
I am Ravula Sankeerthana, Intern posted in the General Medicine Department from 1/12/23 until 31/1/24. 1.SELF REFLECTIVE WRITING ON MY MEDICAL STUDENT CAREER  I  started seeing cases from my 3rd semester posting which was my very first experience with the clinics, It was very overwhelming pretty much the entire year. I  learned lot from my professor , some times I find myself suprised by hearing about cases and the way they approach the understanding of each case and linking the history about the case to diagnose the case and to explain how to understand a case and to diagnose a case. My 1st case I saw in detail  was Heart failure in gm posting so I studied the case in detail  during my posting along with understanding where my pgs , faculty helped to take history step by step. Here is the link of the case http://ravulasankeerthanarollno134.blogspot.com/2022/10/a-75-old-female-with-chief-complaints.html During my general medicine posting as an intern,it started with peripherals which a
Read more

4O/F CAME WITH THE C/O PAIN IN UPPER AND LOWER BACK SINCE 2 YEARS

Image
This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted.  A
Read more

A 53 year old male came with the c/o fever, facial puffiness ,yellowish discoloration of eye

Image
This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted .  C
Read more