Académique Documents
Professionnel Documents
Culture Documents
Name : Ms Z
Gender : Female
Race : Malay
Religion : Islam
Occupation : Housewife
Address : Klang
CHIEF COMPLAINT
Her son noticed that she has a squint.
PHYSICAL EXAMINATION
GENERAL EXAMINATION
Patient was sitting comfortably on her bed. She was alert,
conscious and well oriented to time, place and person. ID tag was
present on her left wrist. She was not in respiratory distress, no
signs of pallor or jaundice. She was large built with good
hydration and nutritional status.
VITAL SIGNS
Temperature : 37.0 C
(afebrile)
Weight : 95 kg
Height : 166 cm
BMI : 34 kgm-2
OCULAR EXAMINATION
1) VISUAL ACUITY
2) INSPECTION
There was no syndromic feature on patients face.
4) DIRECT OPHTALMOSCOPY
6) VISUAL FIELD
sensory : normal
reflex : normal
no facial asymmetry
no parotid enlargement
upper and lower motor neuron are intact
SUMMARY
Supporting points:
She was noticed by her son that she could not move her
right eye to the right.
On examination, patient could not perform abduction of
the right eye, but adduction was done very well.
Patient has multiple underlying factors: diabetes mellitus
for 9 years and has a history of carbuncle removal surgery
twice indicating uncontrolled diabetes. Besides, she has
been diagnosed with hypertensive and dyslipidemia as
well.
DIFFERENTIAL DIAGNOSIS
Proposed investigations:
Full blood count (FBC) to look for signs of infection and
anemia from the white cell count and hemoglobin level
respectively.
HbA1c level to ensure whether patients diabetes is
controlled since the last 3 months.
Fasting blood sugar (FBS) - to check whether patients
blood sugar is controlled.
Renal function test to check for Creatinine level as a sign
of diabetes complication.
Urine FEME (UFEME) to look for presence of albuminuria
as a sign of diabetes complication.
PROPOSED TREATMENT
Patient is admitted to the eye ward in order to control her
blood sugar since diabetes is the primary cause of the palsy.
Plan the right time for patients right eye cataract surgery
only after the abducens nerve palsy is totally treated.
Once she is discharged, patient needs to continue taking her
medications for diabetes, hypertension and dyslipidemia and
come for regular follow up to ensure her condition is stable
and under control.
DISCUSSION
2. http://emedicine.medscape.com/article/1198383-overview