CASE

PRESENTATION
BY,
IRENE SUSAN ALEX
BPHARM 2015
KH.PH.U4BPH15030
DEMOGRAPHIC DETAILS

MRD NO: 2006922
AGE: 63
WARD: B – ECHS GENERAL BED NO:18
SEX: MALE
DEPARTMENT: GENERAL MEDICINE
HEIGHT: 169 cm
WEIGHT: 86 Kg
DATE OF ADMISSION: 27/9/2018
DATE OF DISCHARGE: 1/10/18
REASON FOR ADMISSION:
Left eye pain with diminished
vision
PAST MEDICAL HISTORY:
Hepatitis–B ,5 Yrs
FAMILY HISTORY: Diabetitus
ALLERGIES: NIL
HISTORY OF PRESENT ILLNESS
Mr. Suresh, 37 year old male ,no known co-
morbidities, came with complaint of left eye pain
with diminished vision of the last 2 days.
Apparently well 7 days back, following which he
developed left eye pain , which was persistent
associated with lacrimation. Since last 2 days , he
complaints of diminished vision of the same eye.
He was evaluated outside and was found to have
elevated blood pressure (230/140 mmHg). He
was referred here for further management. No
H/O fever. No H/O headache/body pain.
OBJECTIVE
 VITAL SIGNS
PULSE RATE: 80/min
BP: 200/120 mm Hg
RR: 18/min
TEMP: Afebrile
 CLINICAL EXAMINATION
 No Pallor
 No icterus, clubbing, lymphadenopathy,
cyanosis.
 Systemic examination:
CVS: S1 S2 heard
normally, no murmurs.
RS: Normal vesicular breath sounds,
no added sounds
GIT- soft, non tender, no organomegaly.
CNS- tone:
normal
LAB INVESTIGATION-
HAEMATOLOGY
TESTS 28/9/2018 NORMAL
HAEMOGLOBIN(g/dl) 13.6

PCV (%)

PLATELET (ku/ml)
Total leukocyte count
(ku/ml)

Neutrophil (%)

Lymphocyte (%)

Eosinophil (%)

ESR (mm/1st hour)