CASE PRESENTATION

S. Suchitra
3rd Year MBBS
MVJ Medical College and Research Hospital
DEMOGRAPHIC DATA
o Name: Mrs. XYZ
o Age: 65 years
o Gender: Female
o Occupation: Farmer
o Address: Gautam Colony, KEB Circle Hoskote.
o Income : Rs. 4000 /month
o Socio economic status: Upper Middle Class
(Mod. BG Prasad Classification)
o Date of Admission: 28th January 2020.
o Date of Examination : 29th January 2020.
CHIEF COMPLAINS
 Diminution of vision in right eye since 2 years.
HISTORY OF PRESENTING ILLNESS.
Patient was apparently normal 2 years back after
which she noticed diminution of vision in the right
eye which was insidious in onset, gradually
progressive and painless.
Both for far and near vision.
Vision improves in bright light compared to dim
light.
 No history of glare
 No history of uniocular diplopia

 No history of colored halos

 No history of blackspots

 No history of redness and pain

 No history of watering or discharge

 No history of browache or headache

PAST HISTORY
 Patient is known case of Diabetes Mellitus since 5
years and is under regular medication.
 No history of hypertension, asthma or any chronic
illnesses.
 Patient had similar complains in the left eye 1 year
back for which she consulted an ophthalmologist
and has undergone surgery in the left eye.
Patient used eye drops after surgery for 1 month
which has been tapered and stopped. No history of
use of spectacles.
FAMILY HISTORY
 No significant family history
PERSONAL HISTORY

 Diet: Mixed
 Appetite: Normal

 Sleep: Adequate

 Bowel & Bladder habits: Regular

 No ill habits.
SUMMARY
This is a case of a 65 years old female farmer a
known case of diabetes presenting with complain of
diminution of vision in right eye since 2 years and
has undergone surgery in the left eye 1 year back.
GENERAL PHYSICAL EXAMINATION
Patient aged about 65 years conscious,
cooperative, well oriented to time, place and
person.
Moderately built and well nourished.
Height = 160cm Weight = 70kg
BMI = 27.3 kg/m2
 No pallor.
 No icterus.
 No cyanosis.
 No clubbing.
 No generalized lymphadenopathy.
 No edema.
Vitals:
1. Pulse rate: 76beats/min
2. Blood pressure: 130/80 mm of Hg of left arm in
sitting position
3. Respiratory rate: 17cycles/min, thoracoabdominal
type
4. Temperature: Afebrile
 SYSTEMIC EXAMINATION
 Cardiovascular system:
Sounds S1 and S2 heard. No murmurs

 Respiratory system
Normal vesicular breath sounds heard.

 Abdominal examination.
No mass per abdomen
No organomegaly
 CNS examination.
No neurological deficit present.
OCULAR EXAMINATION
 Head Posture : Normal
 Facial Symmetry : Symmetrical

 Ocular Symmetry : Symmetrical

 RIGHT SIDE LEFT SIDE
Visual Acuity

Distant Vision Counting fingers at Counting fingers at

3m 6m

Near Vision Not checked Not checked

Pin Hole Not done Not done

 RIGHT SIDE LEFT SIDE

Eyebrows Normal Normal

Eye Lids Normal Normal

Eye Lashes Normal Normal

Conjunctiva Normal Normal

Cornea Arcus Senilis is seen Arcus Senilis is seen

Normal in size, shape, Normal in size, shape,
surface, sensations and surface, sensations and
transparency transparency

Sclera Normal Normal

Anterior Chamber Normal in depth and Normal in depth and

optically clear optically clear
 RIGHT SIDE LEFT SIDE

Iris Normal in color and Normal in color and

pattern pattern

Pupil Round Regular and Round Regular and

reacts to light reacts to light

Pupillary Reaction
Direct Reacts Briskly Reacts Briskly

Consensual Reacts Briskly Reacts Briskly

Greyish white opacity Shimmering Light
Lens is seen Reflex seen
Iris Shadow seen
Lacrimal Roplas negative Roplas negative
Apparatus

Orbital Margins Normal Normal

 RIGHT SIDE LEFT SIDE
Ocular Movements
Ductions
+ +

+ + + +

+ +

Versions Free and Full in all Free and Full in all

direction direction
+ + + +

+ + + +

+ + + +
 PROVISIONAL DIAGNOSIS
 It is a case of
Right eye Senile Immature Cataract
Left eye Pseudophakia.
THANK YOU