OSPITAL NG MAYNILA MEDICAL CENTER Department of Ophthalmology Name: Vergara, Mamerto Age/Sex: 80/M Address: 402 D Navarro, Manila Date of Admission: September 6, 2007 Admitting Diagnosis: CSM OS Final Diagnosis: Pseudophakia, OD Date of Discharge: September 7, 2007 Physicians-in-charge: Drs. Reyes/Mateo/Sumajit Clerk-in-charge: Viar/ Villanueva/Villarama Patient Discharge Summary This is a case of an 80 year old male from Manila who came in due to blurring of vision of left eye. History of Present Illness: Five years prior to admission patient noted blurring of vision described as cloudy line of vision. Sought consult with a private doctor and was diagnosed to have Cataract OU. Persistence of above symptoms prompted consult at OPD-Ophtha and was advised to undergo surgery hence the admission. Past Medical History: Hpertensive HBP of 180/90 UBP of 150/80. maintained on Plandil 1983 - s/p hernia reduction Quezon Medical Center Family History DM- mother and siblings Previous Eye History: 2001- Cataract Extraction OD - UDMC 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: 180/90 CR: 80 RR: 20 Temp: 37 HEENT: anicteric sclerae, pink palpebral conjunctivae, no cervical lymphadenopathy, no tonsillopharyngeal congestion Visual Acuity OD OS SC 20/70 - 1 CF at 1 ft PH 20/40 -1 NIPH CC SC JC CC Refraction Hospital No: 1458901 Refraction OD OS Objective Rx Subjective Rx Previous RX External Eye Exam Reactive to light 2-3 mm reactive to light 2-3 mm PPC PPC Anicteric sclera EOM Slit Lamp Clear (-)uptake HHhhhH in place IOL clear (-)uptake NS ++ 1x Applanation Tonometry: OD: OS: 6x 1x 1x 6x 1x Fundoscopy OD: (+)ROR, HM, other structures not seen OS: (-)ROR, HM, other structures not seen 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, OS Pseudophakia, OD Plan: For admission Phacoemulsification with PCIOL OS (LA) Course on the Wards Patient was admitted under the service of Drs. Reyes/Mateo/Samaniego. Patient was put on low salt, low fat diet. Vital signs were monitored every 4 hours. Medications given were: 1. Levofloxacin E/S 1 gtts to OU QID Visual Acuity OD: 20/70 -1 20/40-1 , OS : CF at 1 ft - NIPH. Patient’s vital signs are stable. Patient was scheduled for phacoemulsification with PCIOL, OS on local anesthesia under the services of Drs. Reyes, Mateo,Salamida. Consent for the operation was secured. He 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 OS q 10 min, Diclofenac Na E/S 1 gtt to OS q 10 min, and Acetazolamide 250mg/tab 2 tabs 2 hours prior to OR. On the 1st hospital day patient’s Blood pressure was 180/90, pre-op meds given 1 dose of clonidine 75 mcg Sublingual. Patient was wheeled into the operating room. He tolerated to operation well. Post-op medications were: Cephalexin 500mg/cap TID for 7 days, Mefenamic acid 500mg/cap q 6 as needed for pain on full stomach, Plaridex E/S 1 gtt to OS q 1 for the first 24 hours then q4 thereafter, and Gatifloxacin E/S 1 gtt to OS q1 for the first 24 hours then q 4 thereafter. May go home once cleared by Dr. Reyes.
Pages to are hidden for
"Vergara_ Mamerto"Please download to view full document