OSPITAL NG MAYNILA MEDICAL CENTER Department of Ophthalmology Name: Jalocon, Nora Age/Sex: 75/F Address: 1448 Gomez st. Paco Manila Date of Admission: September 6, 2007 Date of Discharge: Admitting Diagnosis: CSHM, OS; Pseudophakia OD Final Diagnosis: CSHM, OS; Pseudophakia OD s/p ECCE with PCIOL, OS (LA) Physicians-in-charge: Drs. Reyes/Mateo/Samaniego Clerk-in-charge: Viar/ Villanueva/Villarama Patient Discharge Summary This is a case of a 75 year old female from Manila who came in due to blurring of vision of left eye. History of Present Illness: Eight months prior to admission, Patient noted progressive blurring of vision of her left eye, described as cloudy line of vision, associated with excessive tearing, eye discharge and dizziness. No redness or eye pain. Two months prior to admission, persistence of above symptoms prompted consult at Ophtha-OPD and was diagnosed to have CSHM, OS and Pseudophakia OD. Bleparitis. Advised to have surgery hence admission Past Medical History: Hypertensive for 3 years. HBP = 190/90 UBP = 170/90 medications taken are metropolol Family History Denies any heredofamilial disease Previous Eye History: 2001- s/p cataract extraction OD at PGH with diagnosis of Cataract OS 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: 140/80 CR: 80 RR: 20 T: 37.1 HEENT: anicteric sclerae, pink palpebral conjunctivae, no cervical lymphadenopathy, no tonsillopharyngeal congestion Visual Acuity OD OS SC 20/80 HM w/ GLP PH 20/50 CC SC JC CC Refraction Hospital No: 1452620 Refraction OD OS Objective Rx Subjective Rx Previous RX External Eye Exam Slightly Reactive to light 2-3 mm reactive to light 2-3 mm PPC PPC Anicteric sclera Opacity EOM Slit Lamp Clear (-)uptake HHhhhH in place IOL clear (-)uptake HM 1x Applanation Tonometry: OD: 14 OS: 14 6x 1x 1x 6x 1x Fundoscopy OD: (+)ROR, HM, DDB, CDR 0.3, AVR? OS: (-)ROR, other structures cannot be seen With Dilation: (+) ROR,sl. CM, DDB, CM, 0.3 CDR, 2:3 AVR (-) H/E (-) ROR 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, OS, Pseudophakia, OD Plan: For admission ECCE WITH PCIOL OS 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. Moxifloxacin E/S 1 gtts to OU QID 2. 3. 4. Imidapril + HCTZ 1 tab OD Clonidine 75 mg/tab sublingual prn if BP >160/100 Simvastatin 40 mg/tab OD at HS Visual Acuity OD: 20/40, OS : HM with GLP, AT OD: 13 OS: 13. NLDI OS: patent, OD: patent. Patient’s vital signs are stable. The patient was scheduled for ECCE with PCIOL, OS on local anesthesia under the services of Drs. Reyes, Salamida, 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. 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.
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