65 yrs old female with Right eye IMSC

 THIS IS AN ONLINE E LOGBOOK 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-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.

65 yrs old female patient presented to the OPD complaining  cloudy vision ,watering of eye and dim vission.

CHIEF COMPLAINTS:-

DOV in Right Eye since one year.

HISTORY OF PRESENT ILLNESS:-

Patient was apparently asymptomatic one year back then she developed DOV in Right eye which was incidious in onset, gradually progressive.

HISTORY OF PAST ILLNESS: 

HTN, DM(6years on glycoryl M2).

TREATMENT OF HISTORY:-

Diabetes - Yes 

Right eye : CF 3mt 06/60

Left eye : 6/36 / 6/24

Hypertension - Yes 

PERSONAL HISTORY:-

She is married and she was detected by cataract earlier.She has cloudy and dim vision,and watery discharge from the eye.

Appetite - Normal 

Bowels - Regular 

Micturition - Normal

Allergies - No 

No habits 

FAMILY HISTORY:-

No family history.

GENERAL EXAMINATION:

Patient is co-operative, conscious & coherent.

Vitals at admission.

Right eye -CF 3M 06/60.

Left eye -6/36 06/34.

Temperature -98.8°F 

Pulse rate -88/min 

Respiration Rate -19/min 

BP - 120/80mmHg

Spo2 - 99%

GRBS - 10.4 mg%

SYSTEMIC EXAMINATION:-

Cardiovascular systems:- S1 S2 heard, No murmurs.

Respiratory system:- No rigidity

Breath sounds - vesicular.

Abdomen:- Tenderness.

Bowel sounds- No. 

PLAN OF CARE :-

RE -SICS + PCIOL.

(Small incision cataract surgery with posterior chamber intraoccular lens)

PROVISIONAL DIAGNOSIS:-