case




This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from global online community

CHEIF COMPLAINTS

35 year old female came with cheif complaints of

-Diminision of vision of right eye since morning 3am

-Headache since 2 days

HOPI

Patient was apparently asymptomatic 2 days back then started developing diffuse headache sudden in onset,gradually progressive associated with neckpain 

No H/O nausea and vomiting,photophobia,phonophobia

Then since morning 3am had sudden painless loss of vision

No H/O ocular trauma or head trauma

No H/O giddiness,LOC,weakness of both UL and LL

No H/O fever,cough,cold,chestpain,palpitations,orthopnea,PND

PAST HISTORY:

H/O some insect bite 2 months back and took herbal medication

N/k/c/o DM,HTN,Epilepsy 

K/c/o hypothyroidism since 5 years and on tab.thyronorm 100 mcg.

GENERAL EXAMINATION:

Patient is conscious coherent and cooperative 

No pallor ,icterus , clubbing,cyanosis,lymphadenopathy ,pedal edema

Vitals : 

BP- 140/90mmhg

PR -90bpm

RR-18cpm

Spo2 99% at room air 

Temperature -98.2F



Cvs: s1,s2 heard ,no Murmurs,jvp not raised 

Rs: BAE,no added sounds ,NVBS, 

P/A: soft, non tender,bowel sounds can be heard 



CNS:

Pt is conscious

Speech is normal



GCS: E4,V5,M6

TONE: RT. LT



        UL NORMAL. NORMAL



        LL NORMAL NORMAL



POWER:



        UL 4/5. 4/5   



        LL 4/5. 4/5



REFLEXES:



        B: 3+ 3+



        T: 2+ 2+



        S: 1+ 1+



        K: 3+ 3+



        A: 2+ 2+



        P: Flexors




06/05/2

OPHTHALMOLOGY REFERRAL:

CRVO







PROVISIONAL DIAGNOSIS:

?CRVO

TREATMENT:

T.Dolo 650mg PO TID

Inj.Zofer 4mg IV BD

Inj.Ultracet 1 amp in 100ml NS IV SOS

Inj.Optineuron 1 amp in 1 NS IV OD




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Hello everyone I'm mythili, an aspiring final year medical student presenting an osce report after garnering the patient informed consent Let's start off by learning the brief history about the patient A35 year old female came with cheif complaints of -Diminision of vision of right eye since morning 3am -Headache since 2 days Delving more into the history Patient was apparently asymptomatic 2 days back then started developing diffuse headache which was sudden in onset,gradually progressive associated with neckpain  No H/O nausea and vomiting,photophobia,phonophobia Then since morning 3am had sudden painless loss of vision No H/O ocular trauma or head trauma No H/O giddiness,LOC,weakness of both UL and LL No H/O fever,cough,cold,chestpain,palpitations,orthopnea,PND What was her last final diagnosis?  The final diagnosis  is CRVO Complete retinal venous occlusion  CRVO? How was the diagnosis made?  Upon opthological examination Dot blot hemorrhage Macular edema Which are characte
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