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12/8/2023 1 Kenaram Das 28/M 2215286468 Kamothe
Medicine at 7:30 pm
Thrombocytopenia.
K/C/O type 2 diabetes mellitus
since 2 years, on medication.
Casualty at 11:30 pm C/O hydroceole.
K/C/O of hypertension since 2
years and type 2 diabetes
mellitues since 5 years, on
medication.
Current BP-140/70mmHg
Current RBS - 118mg/dl
Traumatology at 8:15 p
No Active managem
There is evidence of mild to moderate non proliferative diabetic Strict Sugar control
retinopathy on fundus examination of both eyes at present.
No active manageme
No active manageme
No active manageme
Vd and EXOM of both eyes- cannot be assessed as patient is in altered MLC to be done.
sensorium. O/E of Right eye- Eyelids: edema+ ecchymosisVd and EXOM of Xray orbit- AP and
both eyes- cannot be assessed as patient is in altered sensorium. Rest- lateral, cold
WNL;Of Left eye- WNL compresses
Fundus of both eyes- WNL. if fracture not
On Palpation of Right eye : All orbital margins margins not well felt due to detected.Tab
edema; of Left eye: All orbital margins well felt Vitamin C
adviced.Topical
lubricant given.
Vd of RE- HMCF, PL +ve PR accurate;of LE - 6/6 ( on Rest E app) EXOM of
both eyes- Free, full and painless in all gazes. O/E of Right eye: Eyelids -
Normal, Conjunctiva- Normal, Cornea- Clear, A/C- Shallow, Pupil- 4mm
Sluggishly RTL, Grade 2 RAPD, Lens- SIMC; Of Left eye:WNL
IOP with Goldman Applation tonometry- Of RE: 60mm Hg; of LE: 12mm Hg
, Conjunctiva- Subconjunctival haemorrhage+
phthalmology
-
Visual acuity of both eyes - cannot be assessed accurately as patient is Xray orbit- AP and
uncooperative; follows torchlight (bedside) lateral, cold
EXOM of both eyes- Free, full and painless in all gazes. compresses
O/E: Of Right eye: Eyelids - Edema+, Ecchymosis+, Debris+, CLW measuring if fracture not
2x0.5x0.5 cm on upper eyelid; Conjunctiva-Congestion+, subconjunctival detected.
hemorrhage+, Cornea- Clear,Rest-WNL ; Of Left eye: WNL Tab Vitamin C
Fundus of both eyes: WNL adviced as per
On palpation: Of Right eye- upper and lower orbital margins not well felt peadiatric
due to edema; Of Left eye- upper and lower orbital margins well felt; dosage.Oral and
Procedure-E/D paracaine instilled in right eye. RL wash given and debris topical antibiotics
removed by thorough irrigation under all aseptic precautions. CLW sutured and lubricants
on right upper eyelid under all aseptic precautions under local advised.
anaesthesia.
-
It
Strict BP control.
Strict sugar
control.
Betadine dressing
done.
Oral antibiotics
and
analgesics adviced.
Vd of both eyes- 6/6( on Rest-E app) EXOM of both eyes- Free, full and MLC to be done.
painless in all gazes; XRay- Anterior
O/E of Right eye- Eyelids:Edema+, Conjunctiva- Subconjunctival Posterior and
haemorrhage+, Cornea- clear, Rest-WNL; of Left eye-WNL; Fundus of both Lateral view
eyes- WNL. adviced; Cold
On Palpation of RE:Both orbital margins not well felt due to edema; Of LE: compress if
Both orbital margins well felt. fracture not
detected. Tablet
Vitamin C adviced.
Vd of both eyes- 6/6( on Rest-E app) EXOM of both eyes- Free, full and Topical lubricating
painless in all gazes; drops, antibiotics
O/E of Right eye- Eyelids: Normal, Conjunctiva- Subconjunctival given.
haemorrhage, Cornea- clear, Rest-WNL; of Left eye- Eyelids: normal
Conjunctiva- subconjunctival haemorrhage, Rest-WNL; Fundus of both
eyes- WNL.
On Palpation - Both orbital margins well felt
No active manageme
There is no evidence of papilloedema on fundus examination of both No active manageme
eyes at present.
Vd of both eyes - 6/9 ( on Rest E app) EXOM of both eyes- Free, full and Xray orbit- AP and
painless in all gazes. O/E of Right eye: WNL; Of Left eye: Eyelids -CLW lateral, cold
measuring 1.5×1×1 cm on the lower eyelid+, compresses if
Rest- WNL fracture not
Fundus of both eyes: WNL detected. Betadine
On Palpation - Both orbital margins well felt dressing Oral
Procedure-CLW sutured on left lower eyelid under all aseptic precautions antibiotic,
under local anaesthesia. analgesic, topical
antibiotic and
lubricant given.
Vd and EXOM of both eyes- cannot be assessed as patient is in altered Cold compresses
sensorium. O/E of Right eye: WNL; O/E of Left eye- Eyelids: edema+ adviced
ecchymosis+, abrasions+; Rest-WNL Betadine ointment
Fundus of Left eye- WNL. to be applied over
On Palpation of Right eye : All orbital margins margins well felt; of Left eye: the abrasions
All orbital margins not well felt due to edema.
There is evidence of retinal haemorrhages and no evidence of Continue paediatric
papilloedema on fundus examination of right eye at present.
Faculty informed
Dr Kashyap
e management.
Dr Gargi
Dr. Gargi
Dr Kashyap
Dr Kashyap
Dr Kashyap
Dr Kashyap
Dr Kashyap
Dr Kashyap
Faculty informed
Dr Kashyap
Dr Kashyap
Dr Kashyap
Dr Kashyap
Dr Faraaz
Faculty informed
Dr Gargi
Dr Gargi
12/19/2022 Follow up
in
ophthalm
ology opd
for
further
managem
ent once
the
patient is
stable
and
discharge
d.
Dr Kashyap
Dr Kashyap
Dr Kashyap
Dr Kashyap
Dr Gargi
Dr Kashyap
Dr Gargi
Dr Gargi
Dr Gargi
Dr Kashyap
Dr Kashyap
Dr Kashyap
Dr Kashyap
Dr Kashyap
Dr Kashyap
MGM Department of Ophthalm
OBGY , 4PM,
Fundus call for
29-07-2020 1 Kajal Jadhav 21/F Kadamboli Eclampsia
MGM Department of Ophthalmology
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