- Name: Mrs. K K
- Age: 44 years
- Sex: Female
- Date of visit: 10-04-2004
Chief complaints:
Foggy vision in the Rt. eye since Feb. 2003. Was in London at that time and was treated with steroid injections and tablets. She felt better from April to June 2003, but the symptoms returned again. In Dec. 2003, she had black patches in front of her vision in the Lt. eye with a sensation of a ball in the eye. The objects appear smaller and the vision is hazy- as if looking through smoke. She also has a non-healing ulcer in the nostrils after a septoplasty in 1979-1980. The wound has never healed and there is a scab formation. She aslo has a tendency to sinusitis. Pain in both the shoulders since 2 weeks along with a general body ache < lifting slight weight.
Life Situation and Mind:
She is a Chartered Accountant and was working with a company before she left for London.
She has been ambitious about her studies and career since childhood. She won’t give up too easily.
She wants things in order. Everything must be in its proper place.
She is hot tempered and is angry at trifles. She screams and shouts from anger. She cannot bear to be cheated.
She likes to help others and goes out of her way to make people comfortable.
She is religious and has a lot of faith in God.
She fears being alone; darkness
Sleep:
Often disturbed from worries about family matters. Fears ghosts when in bed.
Patient as a Person:
- Appetite: Good
- Desires: nil
- Aversion: sweets
- Thirst: normal
- Sweat: scanty
- Stools: normal
- Urine: normal
- Chilly patient
Gyn. & Obst. History:
- FMP: 13 years
- LMP: 2-4-04
- Pr. M P: 6 days/21-25 day
- Quantity: profuse
- Colour: bright red
- Clots: nil
- Odour: nil
- Stains: nil
- Before Menses: headache, weakness
- During Menses: nothing particular
- After Menses: feels fresh and nice
- Leucorrhoea: yellowish white < Menses B2 and A
- Pregnancies: 2 FTNDs
- Abortions: nil
- Contraceptives: IUCD
Past History:
- Chicken pox, Mumps and Measles in childhood
- Tosillectomy- 12 years age, Nasal septoplasty- 30 years age
Family History:
- Father- CVA
- Mother- HT, Hysterectomy (adherent placenta)
- Son- Albinism
Examination findings:
BP: 140/84 mm Hg.
Treatment:
Phosphorus 200 tds x 2 weeks
Follow up:
27-04-2004: Strain in Lt. eye >>. Rt. eye still feels strained. Redness of both eyes in the morning on waking. Objects appear smaller.
Treatment- SL tds x 2 weeks.
12-05-2004: Lt. eye vision >. Rt. eye still dim. Redness of the eyes >. Steroids were reduced by the ophthalmic surgeon.
Treatment- Phos 200 tds x 2 weeks and SL tds x 2 weeks.
10-06-2004: Vision improved in both eyes. Mild pain around rt. eye. Floaters+ Treatment- Phos 200 tds x 1 week and SL tds x 1 week
24-06-2004: Eyes >3. No redness in the morning. Lt. eye feels ‘relaxed’. Rt. eye- floaters +. (S/B Opthalmic surgeon on 26-5-2004: FFA was done- no evidence of active inflammation; Resolving choroiditis in Lt. eye and ant. Uveitis in rt. eye)
Treatment- Phos 200 tds x 2 weeks and SL tds x 2 weeks.
13-07-2004: Dark spot in front of vision in the rt. eye in the periphery of vision.
Blurred vision in the rt. eye and pain in the supra ciliary region. (S/B Ophthalmic surgeon: Healed choroiditis in lt. eye and Uveitis in Rt. eye.)
Treatment- Phos 1M tds x 2 weeks and SL tds x 2 weeks.
10-08-2004: (S/B Ophthalmic surgeon on 4-8-2004: both eyes quiet. Steroids tapered further.) Pain in Rt. eye >. Floaters reduced. Scabs in nostril > 90%.
Treatment- Phos 1M tds x 2 weeks and SL tds x 2 weeks.
This patient has been followed up till 29-9-2005 and has been given Phos 1M on 23-9-2004, 25-11- 2004,17-2-2005 for a period of 1 week with SL being given the rest of the time.
She was last seen at the L.V. Prasad eye hospital at Hyderabad on 10-5-2005 and was found to be clinically normal in both the eyes. All the allopathic medicines had gradually been discontinued by this time.