60 year old male patient presented to OPD with the chief complaints of blurred vision of left eye from past 1 year

 February 26/02/2022

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.

Date of admission 21/02/2022.

Cheif complaint: 

60 year old male patient presented to OPD with the chief complaints of blurred vision of left eye from past 1 year 

History of present illness 

The patient was apparently asymptomatic 2years back then he developed blurred vision  

Intially it was normal then he developed dov in the left eye 

It was small first but increased gradually

DAILY ROUTINE

He was a farmer 10 years back. Whose daily past routine is to wakeup at 6am in the morning having some tea along with breakfast. Usually works in the farm till the evening. Later he completes dinner and sleeps by 9pm.

Daily routine (present) : not clear. 

PAST HISTORY:


Known case of Hypertension since 10 years and he is on medication

Not a known case of diabetes, tb, epilepsy, asthma

One month back, the patient had undergone cataract surgery to his left eye



PERSONAL HISTORY

No history , diabetes, asthma, tuberculosis 

No history of epilepsy

No history of CAD

He is also known case of hypertension and he is  on medication 

PERSONAL HISTORY:


appetite : normal.


Diet : mixed.


Bowels : regular


Micturition : normal


The patient is an occasional alcoholic

No allegric to drugs 

Treatment History 


GENERAL EXAMINATION:

The patient was , conscious, cooperative, thin built.

No icterus

No pallor

No cyanosis

No lymphadenopathy

No clubbing

No edema .

VITALS:

Temperature : afebrile

BP : 170/120mmhg

Pulse: 90bpm

Respiration :20cpm

SPO2 at room 98

Investigation 

RIGHT EYE 



LEFT EYE 


Provisional diagnosis 

Brown cataract

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