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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
08/22/15 Free Template from www.brainybetty.com 3
Presenting Complaints
 Diminution of vision in Right Eye
since 2 months.
 Single episode of pain in Right
Eye 1 month ago.
08/22/15 Free Template from www.brainybetty.com 4
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.
08/22/15 Free Template from www.brainybetty.com 5
History of Present Illness
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.
08/22/15 Free Template from www.brainybetty.com 6
History of Present Illness
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
08/22/15 Free Template from www.brainybetty.com 7
History of Present Illness
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
08/22/15 Free Template from www.brainybetty.com 8
History of Present Illness
No h/o burning micturition
No h/o ocular trauma
No h/o convulsions
h/o tobacco intake present
08/22/15 Free Template from www.brainybetty.com 9
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.
08/22/15 Free Template from www.brainybetty.com 10
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.
08/22/15 Free Template from www.brainybetty.com 11
Past History
No history of similar complaints in the
past.
No h/o Diabetes Mellitus
No h/o Hypertension
08/22/15 Free Template from www.brainybetty.com 12
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
08/22/15 Free Template from www.brainybetty.com 13
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.
08/22/15 Free Template from www.brainybetty.com 14
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.
08/22/15 Free Template from www.brainybetty.com 15
Examination
No evidence of Pallor
No evidence of Icterus
No evidence of Clubbing
No evidence of Cyanosis
No evidence of Lymphadenopathy
08/22/15 Free Template from www.brainybetty.com 16
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
08/22/15 Free Template from www.brainybetty.com 17
Examination
Central Nervous System: Higher Mental
functions intact
Dysphonia present.
On examination both side Vocal chords
are fixed.
08/22/15 Free Template from www.brainybetty.com 18
Ocular Examination
Head Posture : Erect
Facial symmetry: Symmetrical
Ocular Posture: Normal
Extra-ocular movements
08/22/15 Free Template from www.brainybetty.com 19
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
08/22/15 Free Template from www.brainybetty.com 21
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
08/22/15 Free Template from www.brainybetty.com 22
Color vision –
Patient is color blind
08/22/15 Free Template from www.brainybetty.com 23
Anterior Segment- OD
08/22/15 Free Template from www.brainybetty.com 24
Anterior Segment- OD
08/22/15 Free Template from www.brainybetty.com 25
Anterior Segment- OS
08/22/15 Free Template from www.brainybetty.com 26
Anterior Segment- OS
08/22/15 Free Template from www.brainybetty.com 27
Anterior Segment- OS
08/22/15 Free Template from www.brainybetty.com 28
Posterior Segment -OD
08/22/15 Free Template from www.brainybetty.com 29
Posterior Segment -OD
08/22/15 Free Template from www.brainybetty.com 30
Posterior Segment -OS
08/22/15 Free Template from www.brainybetty.com 31
Posterior Segment -OS
08/22/15 Free Template from www.brainybetty.com 32
Fundus Flourescein Angiography
OD 00:12 min
08/22/15 Free Template from www.brainybetty.com 33
Fundus Flourescein Angiography
OD 00:18 min
08/22/15 Free Template from www.brainybetty.com 34
Fundus Flourescein Angiography
OD 00:22 min
08/22/15 Free Template from www.brainybetty.com 35
Fundus Flourescein Angiography
OD 00:28 min
08/22/15 Free Template from www.brainybetty.com 36
Fundus Flourescein Angiography
OD 00:56 min
08/22/15 Free Template from www.brainybetty.com 37
Fundus Flourescein Angiography
Os 01:24 min
08/22/15 Free Template from www.brainybetty.com 38
Fundus Flourescein Angiography
Os 01:24 min
08/22/15 Free Template from www.brainybetty.com 39
Fundus Flourescein Angiography
Os 01:24 minOs 13:56 min
08/22/15 Free Template from www.brainybetty.com 40
B SCAN- OD
08/22/15 Free Template from www.brainybetty.com 41
08/22/15 Free Template from www.brainybetty.com 42
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
08/22/15 Free Template from www.brainybetty.com 43
OD
• Retina attached elsewhere
• Choroidal thickness normal
elsewhere
• Optic nerve head appears normal
08/22/15 Free Template from www.brainybetty.com 44
B SCAN-OS
08/22/15 Free Template from www.brainybetty.com 45
OCT- OD
08/22/15 Free Template from www.brainybetty.com 46
OCT- OD
08/22/15 Free Template from www.brainybetty.com 47
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
08/22/15 Free Template from www.brainybetty.com 48
Peripheral Smear- Normocytic hypochromic
anaemia with leucocytosis
Bleeding Time: 2:30 min
Clotting Time: 4:00 min
ESR 06 in first hour
08/22/15 Free Template from www.brainybetty.com 49
Urine Microscopy- Within normal limits
No evidence of Albumin or Sugar
HIV negative.
08/22/15 Free Template from www.brainybetty.com 50
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
08/22/15 Free Template from www.brainybetty.com 51
Renal function Tests
Urea: 22 mg/dl
Creatinine: 0.8 mg/dl
08/22/15 Free Template from www.brainybetty.com 52
Lipid Profile
Cholesterol 192 mg/dl
LDL Cholesterol 120 mg/dl
HDL Cholesterol 50 mg/dl
Triglycerides 111mg/dl
08/22/15 Free Template from www.brainybetty.com 53
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.
08/22/15 54
Thankyou.

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Case presentation~cd874

  • 1. Clinical Case Presentation Moderator : Dr. M.I. Magdum Presentor : Dr. Arushi Prakash 12/11/13
  • 2. 08/22/15 Free Template from www.brainybetty.com 2 Patients Details Name : LSB Age: 58 yrs. Sex Male Occupation: Farmer Resident of: Nippani
  • 3. 08/22/15 Free Template from www.brainybetty.com 3 Presenting Complaints  Diminution of vision in Right Eye since 2 months.  Single episode of pain in Right Eye 1 month ago.
  • 4. 08/22/15 Free Template from www.brainybetty.com 4 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.
  • 5. 08/22/15 Free Template from www.brainybetty.com 5 History of Present Illness 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.
  • 6. 08/22/15 Free Template from www.brainybetty.com 6 History of Present Illness 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
  • 7. 08/22/15 Free Template from www.brainybetty.com 7 History of Present Illness 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
  • 8. 08/22/15 Free Template from www.brainybetty.com 8 History of Present Illness No h/o burning micturition No h/o ocular trauma No h/o convulsions h/o tobacco intake present
  • 9. 08/22/15 Free Template from www.brainybetty.com 9 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.
  • 10. 08/22/15 Free Template from www.brainybetty.com 10 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.
  • 11. 08/22/15 Free Template from www.brainybetty.com 11 Past History No history of similar complaints in the past. No h/o Diabetes Mellitus No h/o Hypertension
  • 12. 08/22/15 Free Template from www.brainybetty.com 12 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
  • 13. 08/22/15 Free Template from www.brainybetty.com 13 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.
  • 14. 08/22/15 Free Template from www.brainybetty.com 14 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.
  • 15. 08/22/15 Free Template from www.brainybetty.com 15 Examination No evidence of Pallor No evidence of Icterus No evidence of Clubbing No evidence of Cyanosis No evidence of Lymphadenopathy
  • 16. 08/22/15 Free Template from www.brainybetty.com 16 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
  • 17. 08/22/15 Free Template from www.brainybetty.com 17 Examination Central Nervous System: Higher Mental functions intact Dysphonia present. On examination both side Vocal chords are fixed.
  • 18. 08/22/15 Free Template from www.brainybetty.com 18 Ocular Examination Head Posture : Erect Facial symmetry: Symmetrical Ocular Posture: Normal Extra-ocular movements
  • 19. 08/22/15 Free Template from www.brainybetty.com 19 Visual Acuity
  • 20. + 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
  • 21. 08/22/15 Free Template from www.brainybetty.com 21 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
  • 22. 08/22/15 Free Template from www.brainybetty.com 22 Color vision – Patient is color blind
  • 23. 08/22/15 Free Template from www.brainybetty.com 23 Anterior Segment- OD
  • 24. 08/22/15 Free Template from www.brainybetty.com 24 Anterior Segment- OD
  • 25. 08/22/15 Free Template from www.brainybetty.com 25 Anterior Segment- OS
  • 26. 08/22/15 Free Template from www.brainybetty.com 26 Anterior Segment- OS
  • 27. 08/22/15 Free Template from www.brainybetty.com 27 Anterior Segment- OS
  • 28. 08/22/15 Free Template from www.brainybetty.com 28 Posterior Segment -OD
  • 29. 08/22/15 Free Template from www.brainybetty.com 29 Posterior Segment -OD
  • 30. 08/22/15 Free Template from www.brainybetty.com 30 Posterior Segment -OS
  • 31. 08/22/15 Free Template from www.brainybetty.com 31 Posterior Segment -OS
  • 32. 08/22/15 Free Template from www.brainybetty.com 32 Fundus Flourescein Angiography OD 00:12 min
  • 33. 08/22/15 Free Template from www.brainybetty.com 33 Fundus Flourescein Angiography OD 00:18 min
  • 34. 08/22/15 Free Template from www.brainybetty.com 34 Fundus Flourescein Angiography OD 00:22 min
  • 35. 08/22/15 Free Template from www.brainybetty.com 35 Fundus Flourescein Angiography OD 00:28 min
  • 36. 08/22/15 Free Template from www.brainybetty.com 36 Fundus Flourescein Angiography OD 00:56 min
  • 37. 08/22/15 Free Template from www.brainybetty.com 37 Fundus Flourescein Angiography Os 01:24 min
  • 38. 08/22/15 Free Template from www.brainybetty.com 38 Fundus Flourescein Angiography Os 01:24 min
  • 39. 08/22/15 Free Template from www.brainybetty.com 39 Fundus Flourescein Angiography Os 01:24 minOs 13:56 min
  • 40. 08/22/15 Free Template from www.brainybetty.com 40 B SCAN- OD
  • 41. 08/22/15 Free Template from www.brainybetty.com 41
  • 42. 08/22/15 Free Template from www.brainybetty.com 42 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
  • 43. 08/22/15 Free Template from www.brainybetty.com 43 OD • Retina attached elsewhere • Choroidal thickness normal elsewhere • Optic nerve head appears normal
  • 44. 08/22/15 Free Template from www.brainybetty.com 44 B SCAN-OS
  • 45. 08/22/15 Free Template from www.brainybetty.com 45 OCT- OD
  • 46. 08/22/15 Free Template from www.brainybetty.com 46 OCT- OD
  • 47. 08/22/15 Free Template from www.brainybetty.com 47 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
  • 48. 08/22/15 Free Template from www.brainybetty.com 48 Peripheral Smear- Normocytic hypochromic anaemia with leucocytosis Bleeding Time: 2:30 min Clotting Time: 4:00 min ESR 06 in first hour
  • 49. 08/22/15 Free Template from www.brainybetty.com 49 Urine Microscopy- Within normal limits No evidence of Albumin or Sugar HIV negative.
  • 50. 08/22/15 Free Template from www.brainybetty.com 50 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
  • 51. 08/22/15 Free Template from www.brainybetty.com 51 Renal function Tests Urea: 22 mg/dl Creatinine: 0.8 mg/dl
  • 52. 08/22/15 Free Template from www.brainybetty.com 52 Lipid Profile Cholesterol 192 mg/dl LDL Cholesterol 120 mg/dl HDL Cholesterol 50 mg/dl Triglycerides 111mg/dl
  • 53. 08/22/15 Free Template from www.brainybetty.com 53 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.