General Medicine Blog 1
February 26, 2022
This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.
A 55 year old male patient, resident of Konda Mallepally, Shepherd by occupation came to our hospital with chief complaint of blurness of left eye.
Date of admission :- 21/02/2022
History of present illness:-
Patient was apparently asymptomatic 2 years back and developed blurring of vision of left eye especially far objects and since 1 week it was gradually progressing.
History of past illness:-
Patient is known case of diabetes since 7 years and not a known case of hypertension, epilepsy and tb.
Patient had undergone hydrocelectomy 9 years back.
Personal history:-
Patient has normal eating habit with mixed diet.
Occasionally alcholic, no smoking.
Daily routine:-
Patient used to wake up at 5.00AM ,he used to fresh up, does farm work and take breakfast at 10.00AM .Then he used to look up at his goats and he takes lunch in between 1.00PM-2.00PM and dinner at 8.00PM and goes to bed by 9.00PM.
Family history:-
No significant family history.
Pre-operative diagnosis:-
Left Eye Senile Mature Cataract
Post-operative diagnosis:-
Left Eye Pseudophakia
Operative procedure executed:-
Left Eye General Cataract Surgery
General examination:-
Patient is conscious, coherent, cooperative and well oriented to time, place and person.
No pallor
No icterus
No clubbing
No lymphadenopathy
No edema
Vitals:-
Temperature-99 F
Pulse rate- 104 bpm
RBS-104 mg/dl
BP -90/70 mmhg
Investigations:-
XY group test-Negative
RBS
Serology
Pre-operation medication:-
Inj. TT 0.5ml IM
Inj. Xylocaine 0.1ml
Tab. Diamox 250mg BD
Tab. Diazepam @10PM
Treatment:-
E/D Ciplox TID
Glimi-M2 OD
&
Cataract Surgery done.
