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					OSPITAL NG MAYNILA MEDICAL CENTER Department of Ophthalmology Name: Lazarte, Gregorio Age/Sex: 70/M Address: 1718 Rd 1 Bagong Sicat, Punta, Sta. Ana, Manila Date of Admission: September 4, 2007 Admitting Diagnosis: Pseudophakia OS, CSM, OD Physicians-in-charge: Drs. Reyes/Mateo/Gapay Clerk-in-charge: Viar/ Villanueva/Villarama Patient’s 6 hour History This is a case of a 70 year old male from Manila who came in due to blurring of vision of the right eye. History of Present Illness: Patient has been having blurring of vision for the past 30 years, no consult and no medications done until.. 2 years PTC, patient noted progressive blurring of vision with no associated eye pain, but with occasional dizziness. Consult was made at Tondo General Hospital and patient was given unrecalled eye solution as medications and advised surgery but was not done due to financial constraints. Patient noted only slight relief from blurring of vision and noted further progression. Persistence of symptoms and progression of the blurring of vision prompted consult. Past Medical History: (+) HPN x 7 years with highest BP of 170/130 and UBP of 150/100. No maintenance medications, only given unrecalled occasional medications at the health center. Family History Patient claims to have no history of heredofamilial diseases Previous Eye History: (+) s/p cataract extraction April 17, 2007 at Gat Andres Hospital Personal/Social History: Occasional smoker and occasional 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 decreased hearing, no neckpain, no dysphagia, no itchiness, no epistaxis, no hoarseness Respiratory: no difficulty of breathing, nol cough and colds, 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 150/100 CR 81 RR 18 Temp 36.7 HEENT: anicteric sclerae, pink palpebral conjunctivae, no cervical lymphadenopathy, no tonsillopharyngeal congestion Visual Acuity OD OS SC HM 20/40 -2 PH NILP 20/40 +1 CC J- SC J- SC Refraction Hospital No: 1452608

External Eye Exam Not reactive PERTL 2-3 mm PPC PPC

Anicteric sclera White fleshy mass EOM

Slit Lamp

Clear (-) uptake

Clear (-) uptake

IOL in place

1x Applanation Tonometry: OD: 16 OS: 16

6x

1x

1x

6x

1x

Fundoscopy OD: (-)ROR with dilation OS: (+)ROR, clear media, distinct disc border 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: Pseudophakia, OS CSM, OD

Plan:

for work-up and admission

Course on the Wards Patient was admitted under the service of Drs. Reyes/Mateo/Gapay. Patient was put on low salt,low fat diet. Vital signs were monitored every 4 hours. Medications given were: 1. Losartan + HCTZ 1 tab OD before breakfast 2. Captopril 25 mg PRN for BP 160/100 and above 3. Multivitamins tab OD 4. Tobramycin (Tobrex) E/S 1 gtt to OU 4x a day Visual Acuity OD: HM OS :20/50-1  20/40, AT OD: 14 OS: 16. NLDI OD – partially obstructed with clear flow, OS: patent. Patient’s vital signs are stable.


				
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