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OSPITAL NG MAYNILA MEDICAL CENTER Department of Ophthalmology Name: Oliva, Anita Age/Sex: 67/F Address: 154 Calle canto San Juan Batangas Date of Admission: September 6, 2007 Date of Discharge: September 8, 2007 Admitting Diagnosis: CSM OD, CSI OS Final Diagnosis: Pseudophakia, OD; CSI, OS Physicians-in-charge: Drs. Reyes/Mateo/ Clerk-in-charge: Viar/ Villanueva/Villarama Patient Discharge Summary This is a case of a 67 year old female from Batangas who came in due to blurring of vision of both eyes. History of Present Illness: Three years prior to admission, patient noticed blurring of vision of both eyes OS>OD, described as cloudy line of vision. No headache, no loss of consciousness. No consult or medications taken Two months prior to admission, there was progression of the above condition. The patient sought consult at Ophtha – OPD and was diagnosed to have CSM, OD and CSI OS. She was advised to have surgery, hence the admission. Past Medical History: No HPN, BA, DM, Allergies, TB Family History Denies any heredofamilial disease Previous Eye History: January 2007- pterygium removal at san juan de dios Personal/Social History: Non-Smoker Non-alcoholic beverage 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 Physical Examination: General: conscious, coherent, ambulatory, not in cardiorespiratory distress BP: HEENT: anicteric sclerae, pink palpebral conjunctivae, no cervical lymphadenopathy, no tonsillopharyngeal congestion Hospital No: 1446337 Visual Acuity OD OS Refraction OD OS External Eye Exam SC 20/200 20/100 - 1 Objective Rx PH 20/125 20/63 -1 CC 20/125 20/50 SC 10 7 JC CC 16 7 Previous RX Refraction Subjective Rx Reactive to light 2-3 mm reactive to light 2-3 mm PPC PPC Anicteric sclera EOM Slit Lamp Clear (-)uptake HHhhhH ++ central CN clear (-)uptake CN ++ 1x Applanation Tonometry: OD: 14 OS: 14 6x 1x 1x 6x 1x Fundoscopy OD: (+)ROR, HM, other structures not seen OS: (+)ROR, HM, other structures cannot be seen With Dilation: (+) ROR, sl. HM, DDB, CM, 0.3 CDR, 2:3 AVR (-) H/E (-) ROR, sl. HM, DDB, CM, 0.3 CDR, 2:3 AVR (-) 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: CSM, OD CSI, OS Plan: For admission For Phacoemulsification with PCIOL, OD Course in the Wards Patient was admitted under the service of Drs. Reyes/Mateo. Patient was put on low salt, low fat diet. Vital signs were monitored every 4 hours. Medications given were: 1. Moxifloxacin E/S 1 gtts to OU QID 2. Imidapril + HCTZ 1 tab OD 3. Captopril 25 mg/tab PO prn if BP >160/100 Visual Acuity OD: CF at 5 ft - 20/160, OS : 20/160 - 20/63 -2, AT OD: 15 OS: 15. NLDI OS: patent, OD: patent. Patient’s vital signs are stable. Patient was scheduled for phacoemulsification with PCIOL, OD on local anesthesia under the services of Drs. Reyes, Mateo, Daffon, Gapay. 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. On the first hospital day, Visual Acuity OD: 0 NIPH, OS: HM with GLP, AT OD: 9 OS: 11. The patient was prepared for operation. 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. The patient 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, Prednisone acetate E/S 1 gtt to OD q 1, and Gatifloxacin E/S 1 gtt to OD q 4. On the 2nd hospital day, Visual Acuity OD: 20/100 – 1 20/25 -1, OS: 20/50 -1 20/30 -3, AT OD: 11. Patient was sent home with medications: Amoxicillin 500mg/cap TID for 7 days, Mefenamic acid 500mg/cap q6 as needed for pain on full stomach, Prednisone acetate E/S 1 gtt to OD q 1, and Gatifloxacin E/S 1 gtt to OD q 4. Patient was advised on care of the eye and was advised to follow-up on September 13, 2007 at Ophtha-OPD. Patient was welladvised.
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