Case presentation~cd874

Clinical
Case Presentation
Moderator : Dr. M.I.
Magdum
Presentor : Dr. Arushi Prakash
12/11/13

08/22/15 Free Template from www.brainybetty.com 2
Patients Details
Name : LSB
Age: 58 yrs.
Sex Male
Occupation: Farmer
Resident of: Nippani

Presenting Complaints
 Diminution of vision in Right Eye
since 2 months.
 Single episode of pain in Right
Eye 1 month ago.

History of Present Illness
Patient was apparently alright until 2 months
ago when he started developing diminution of
vision in Right Eye which kept on progressing
gradually and painlessly.
He first noticed it while working in the fields
one day that he was unable to recognize faces
infront of him with left eye closed, his vision in
the right eye has progressively been
diminishing since.

About one month ago the patient experienced an
episode of pain in the right eye – sudden in
onset, pricking in character, non radiating for
which he consulted a local doctor who gave
him some eyedrops to be put hourly and
spectacles.
The pain resolved within 2 days but the
diminution of vision has progressed such that
since the past 15 days he is only able to see
objects less than 1m away.

No h/o redness
No h/o watering
No h/o discharge
No h/o colored halos
No h/o micropsia
No h/o metamorphopsia
No h/o flashes of light
No h/o curtain falling infront of eyes

h/o cough since 5 months present
No h/o weakness
No h/o tiredness
No h/o lethargy
No h/o weight loss
No h/o sore throat
No h/o fever

No h/o burning micturition
No h/o ocular trauma
No h/o convulsions
h/o tobacco intake present

Past History
Patient has history of dysphonia since the
past 5 months for which he showed a
local doctor in Nippani, he was told that
it will improve with medications, but
there was no improvement. At the same
time patients developed cough which is
not continous, comes in bouts and has no
aggravating or relieving factors. The
cough has been persisiting for the last 5
months.

Past History
A few days later, at KLESH the patient
underwent an endoscopy and was
diagnosed to be having right sided vocal
cord palsy.
He was prescribed a B-Complex, an
antibiotic tablet (Levofloxacin) for 5 days
and a cough syrup.
It has now progressed to involve both
recurrent laryngeal nerves such that the
patient has no phonation at all.

Past History
No history of similar complaints in the
past.
No h/o Diabetes Mellitus
No h/o Hypertension

Personal History
Diet : Vegetarian
Appetite: Normal
Sleep: Not distubed
Bowel habits: Unaltered
Bladder habits: Unaltered
Substance abuse: Tobacco chewing since
25 years. ( 1 packet for 3 days)
occasional alcohol intake

Family History
No history of similar complaints in the
family.
Patient has 4 brothers and one sister all
of who are alive and healthy.
His father passed away 20 years ago due
to chronic tuberculosis.
His mother is alive and healthy.

Examination
Patient is an elderly male, poorly
nourished, conscious, co-operative and
well oriented to time, place and person.
Pulse Rate: 90/min
Blood Pressure: 110/70 mm Hg
Respiratory Rate: 24/min
Afebrile to touch.

Examination
No evidence of Pallor
No evidence of Icterus
No evidence of Clubbing
No evidence of Cyanosis
No evidence of Lymphadenopathy

Examination
Respiratory System: Bilateral equal air
entry
No adventitious sounds heard
Cardiovascular System: Normal S1, S2
. heard. No murmurs
Per Abdomen: Soft, non tender
No distension
Bowel sounds present

Examination
Central Nervous System: Higher Mental
functions intact
Dysphonia present.
On examination both side Vocal chords
are fixed.

Ocular Examination
Head Posture : Erect
Facial symmetry: Symmetrical
Ocular Posture: Normal
Extra-ocular movements

Visual Acuity

+ 3.00 +2.00
+ 3.00 +2.00
Sph Cyl Axis Sph Cyl Axis
--- --- -- +1.25 --- --
--- --- -- +4.25 --- --
CF ½ mt
Nil
6/36
N-36

Intraocular Pressure
Intraocular pressure{with Schiotz
tonometer (using 5.5g weight) on
12.11.13 at 08:40 a.m.} -
RE -12.2 mm of Hg
LE -14.6 mm of Hg

Color vision –
Patient is color blind

Anterior Segment- OD

Anterior Segment- OS

Posterior Segment -OD

Posterior Segment -OS

Fundus Flourescein Angiography
OD 00:12 min

OD 00:18 min

OD 00:22 min

OD 00:28 min

OD 00:56 min

Os 01:24 min

Os 01:24 minOs 13:56 min

B SCAN- OD

OD
• Lens echo noted
• Vitreous shows few low reflective
dot echoes
• A mass lesion noted in the
peripapillary area and posterior
pole measuring 12.4 x3.5 mm
with high surface reflectivity and
variable internal reflectivity
• Retinal detachment noted inferior
and temporal to the lesion

OD
• Retina attached elsewhere
• Choroidal thickness normal
elsewhere
• Optic nerve head appears normal

B SCAN-OS

OCT- OD

Investigations
Haemoglobin 12.6 gm%
Total Leucocyte Count 2300/cmm
Differential Leucocyte Count N72L25E02M01
Packed Cell Volume 40.6%
Platelet Volume 3.68lacks/cmm
Reticulocyte Count 0.2%
Red Cell Count 5.29million/cmm

Peripheral Smear- Normocytic hypochromic
anaemia with leucocytosis
Bleeding Time: 2:30 min
Clotting Time: 4:00 min
ESR 06 in first hour

Urine Microscopy- Within normal limits
No evidence of Albumin or Sugar
HIV negative.

Liver Function Tests:
Total Bilirubin 0.5 mg/dl
Direct Bilirubin 0.2 mg/dl
Total Proteins 7.2 gm/dl
Serum Albumin 3.8 gm/dl
A:G ratio 1.1
SGOT 16 U/L
SGPT 10 U/L
Alkalline Phosphatase 558 IU/L

Renal function Tests
Urea: 22 mg/dl
Creatinine: 0.8 mg/dl

Lipid Profile
Cholesterol 192 mg/dl
LDL Cholesterol 120 mg/dl
HDL Cholesterol 50 mg/dl
Triglycerides 111mg/dl

X- Ray Chest P-A View
Hilar shadows are within normal limits.
Pulmonary vasculatures appear normal.
Both domes of diaphragm are smooth.
Both costophrenic recesses are clear.
Lung fields appear normal.
Visualized bones and soft tissue shadows
appear normal.

Case presentation~cd874

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