OSPITAL NG MAYNILA MEDICAL CENTER Department of Ophthalmology Name: Banares, Rufina Age/Sex: 69/F Address: 1130-O Penafrancia st. Paco, Manila Date of Admission: September 3, 2007 Date of Discharge: September 8, 2007 Admitting Diagnosis: CSHM, OD; CSI, OS Final Diagnosis: Pseudophakia, OD; CSI, OS Physicians-in-charge: Drs. Reyes/Mateo/Corpuz Clerk-in-charge: Viar/ Villanueva/Villarama Patient Discharge Summary This is a case of a 69 year old female from Paco Manila who came in due to blurring of vision of the right eye. History of Present Illness: Five years prior to admission, patient started to have progressive blurring of vision, described as clouds covering her line of vision associated with headache and dizziness. Four years prior to admission, there was persistence of blurring of vision. Patient sought consult at a private clinic and was diagnosed to have Cataract Senile Immature, OD and was prescribed with an eye solution which did not give relief. One month prior to admission, there was persistence of the above symptoms. The patient sought consult at a private clinic and was diagnosed to have Cataract Senile Mature, OD and was advised to have cataract extraction hence consult at this institution and subsequent admission. Past Medical History: (+) DM – for 4 years maintained on Metformin HCL + Glibenclamide BID No other diseases Family History No known heredofamilial disease Previous Eye History: None Personal/Social History: NonSmoker Occassional alcoholic drinker Review of Systems: Constitutional: no weight loss, no loss of appetite, no chills, no fever Skin: No pigmentation, no itchiness. HEENT: No headache, no tinnitus, no dizziness, no decreased hearing, no neckpain, no dysphagia, no itchiness, no epistaxis, no hoarseness Respiratory: no difficulty of breathing, no cough, no hemoptysis Cardiovascular: no chest pains, no palpitations, no easy fatigability GIT: no abdominal pain, no diarrhea, no melena, no hematochezia GUT: no oliguria, no anuria, no dysuria Endocrinology: no polydipsia, polyphaga, polyuria Hematology: no bleeding tendencies, no easy bruisability Neurology: no seizure, no tremors, no loss of consciousness Hospital No: 1454695
Physical Examination: General: conscious, coherent, ambulatory, not in cardiorespiratory distress HEENT: anicteric sclerae, pink palpebral conjunctivae, no cervical lymphadenopathy, no tonsillopharyngeal congestion Visual Acuity OD OS Refraction OD OS SC GLP 20/80 (+1) Objective Rx PH NIPH 20/50 CC SC 16 (-1) Subjective Rx Previous RX CC Refraction
External Eye Exam Reactive to light 2-3 mm
1x Applanation Tonometry: OD: 11 OS: 11
Fundoscopy OD: (-)ROR, other structures cannot be seen OS: (+)ROR, CM, DDB, CDR 0.3 AVR 2:3 (-)H/E Chest and Lungs: Symmetric chest expansion, no retractions, clear breath sounds Heart: Adynamic precordium, bradycardic, regular rhythm, no murmurs Abdomen: flabby, normoactive bowel sounds, soft, nontender, no organomegaly Extremities: grossly normal, no edema, no cyanosis, full and equal pulses Assessment: CSHM, OD; CSI, OS Plan: ECCE with PCIOL
Course in the Wards Patient was admitted under the service of Drs. Reyes/Mateo/Corpuz. Patient was put on DM diet. Vital signs were monitored every 4 hours. Medications given were: 1. Metformin + Glibenclamide tab BID 2. Simvastatin 40 mg tab OD 3. Vigamox E/S 1gtt to OU QID Visual Acuity OD: HM with GLP, OS : 20/100-2 - 20/50 -2, AT OD: 12 OS: 23. NLDI OS: clear outflow, OD: patent. Patient’s vital signs are stable. On the first hospital day. Patient’s vital signs were stable. Visual acuity OD: HM with GLP, OS: 20/200 - 20/50 -2. Present medications and management are continued. The patient was scheduled for ECCE with PCIOL on local anesthesia under the services of Drs. Reyes, Salameda, Samaniego. Consent for the operation was secured. She was put on NPO post midnight. The patient was advised full facial, oral and body hygiene prior to OR. Medications given include Tropicamide E/S 1 gtt to OD q 10 min, Diclofenac Na E/S 1 gtt to OD q 10 min, and Acetazolamide 250mg/tab 2 tabs 2 hours prior to OR. On the 2nd hospital day, the patient was wheeled in to the operating room with stable vital signs. She tolerated the operation well. After the operation, she was put on diet as previously ordered. Vital signs were monitored every 15 mins for the first hour, then every 30 mins for the second hour, then q1 until stable. Medications given were: Amoxicillin 500mg/cap TID for 7 days, Mefenamic acid 500mg/cap q 6 as needed for pain on full stomach, 5% NaCl E/S 1 gtt to OD q 1, Prednisolone acetate E/S 1 gtt to OD q 1, and Gatifloxacin E/S 1 gtt to OD q 4. On the 3rd hospital day, patient vital signs were stable. Visual Acuity OD: 10/200 20/200, 20/70 20/50, AT OD: 14, OS: 10. Previous management was continued. On the 4th hospital day, patient vital signs were stable. Visual Acuity OD: 10/200 20/70, 20/70 20/50, AT OD: 14, OS: 10. Previous management was continued. On the 5th hospital day, patient vital signs were stable. Visual Acuity OD: 20/70 -1 20/70 20/200, 20/70 20/70 +1. She was given may go home orders. Home medications were: amoxicillin 500mg/cap TID for 7 days, Mefenamic acid 500mg/cap q 6 as needed for pain on full stomach, 5% NaCl E/S 1 gtt to OD every hour, Prednisolone acetate E/S 1 gtt to OD q 1, and Gatifloxacin E/S 1 gtt to OD q 4. She was advised to return for follow up on September 11, 2007 at 8:00 AM.