Diminution of vision in the eyes





Date of admission :-11-09-2023

CHIEF COMPLAINTS:-

A male patient of age 77 years old resident of Nakirekal  presented to the OPD with  chief complaints of 

1)diminution of vision in both eyes since 2 years 

HISTORY OF PRESENTING ILLNESS:-

Patient was apparently asymptomatic 2 months ago and he developed diminution of vision which was insidious in onset and gradually progressive in nature . 

It was not associated with watering , photophobia , redness or itching . 

HISTORY OF PAST ILLNESS:-

There was a history of stent surgery related to CHD 1 year ago 

There was a history of auditory and visual hallucinations since 1 year and was diagnosed 1 month ago .

K/C/O of DM 2 since months 

Not K/C/O of asthma , epilepsy , Tb 

TREATMENT HISTORY:-

1) Metformin 500 mg 

2) risperidone 2 mg 

PERSONAL HISTORY:-

Sleep : inadequate 

Appetite : loss of appetite 

Bladder and bowel : regular 

Drug allergies : no 

Addictions : no 

FAMILY HISTORY:-

Not significant


PHYSICAL EXAMINATION:- 


1) general examination: 


Height - 

Weight - 

Pallor-no

Icterus - no 

Cyanosis - no 

Clubbing - no 

Pedal Edema - no 

Temperature - 98 f 

Pulse rate - 78 bpm

Respiratory rate - 17 cpm 

Spo2 - 98 % 

Grbs-  136 mg % 


2) systemic examination: 


CVS - s1 , s 2 heard 

CNS - 

Respiratory - 

Provisional Diagnosis:-

Left eye senile mature cataract 

INVESTIGATIONS:- 

RBS:-


RFT:-


HBsAg:-                                                                   


Anti HCV antibodies:-


HIV:- 


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