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OSPITAL NG MAYNILA MEDICAL CENTER Department of Ophthalmology Name: Anasco, Lolita Age/Sex: 75/F Address: Sta. Cruz Manila Date of Admission: September 11, 2007 Date of Discharge: September 12, 2007 Admitting Diagnosis: CSM, OD; Pseudophakia, OS Final Diagnosis: Pseudophakia, OU Physicians-in-charge: Drs. Reyes/Daffon/Samaniego Clerk-in-charge: Viar/ Villanueva/Villarama Hospital No: 1460185 REF: 502 ØB : 6.00 mm ØT : 12.00 mm POWER: 21.50 D LOT: 612079 SN: 612079 019 Patient’s Discharge Summary This is a case of a 75 year old female from Manila who came in due to blurring of vision of right eye. History of Present Illness: Patient is S/P cataract extraction, OS (2002) at UDMC. She has been experiencing progressive gradua; blurring of vision of right eye with no other signs and symptoms. Persistence of above symptoms prompted consult at Ophtha-OPD and was advised to undergo eye operation, hence admission. Past Medical History: (-) HPN, DM, BA, Allergy, PTB Family History (+) HPN – brother and father Previous Eye History: S/P cataract extraction, OS – 2002 UDMC S/P DCT Right, august 2007 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, no 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: 120/80 mmHg HR: 70 RR: 18 T: 36.7 HEENT: anicteric sclerae, pink palpebral conjunctivae, no cervical lymphadenopathy, no tonsillopharyngeal congestion Visual Acuity OD OS SC 20/50 -1 20/40 -1 PH 20/32 20/25-1 CC SC JC CC Refraction 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 ++ CN clear (-)uptake IOL in place 1x Applanation Tonometry: OD: 10 OS: 10 6x 1x 1x 6x 1x Fundoscopy OD: (+)ROR, SHM, other structures not seen OS: (+)ROR, SHM,DDB, CDR 0.3 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; Pseudophakia, OS S/P DCT, Right Plan: For admission Phaco with PCIOL, OD Course on the Wards Patient was admitted under the service of Drs. Reyes/Mateo/Samaniego. Patient was put on regular diet. Vital signs were monitored every 4 hours. Medications given were: 1. Levofloxacin E/O apply 1 drop to OU every 6 hours Patient was allowed to go out on pass and was advise to come back at 6 A.M. On the first hospital day Visual Acuity OD: 20/40-1 - 20/40 + 1, OS : 20/50 + 2 - 20/20 -2, AT OD: 9 OS: 6. Patient’s vital signs are stable. Pre-operative orders were: The patient was scheduled for Phacoemulsification with PCIOL, OD under local anesthesia under the services of Drs. Reyes, Daffon, 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. The patient tolerated the operation well. She was transferred to ward and was seen by Dr. Reyes. Home medications were: Cefalexin 500mg/cap TID for 7 days, Mefenamic acid 500mg/cap q 6 as needed for pain on full stomach, Levofloxacin E/S 1 gtt to OD for the 1st 24 hours then q 4 thereafter , and Maxidex E/S 1 gtt to OD q 1 for the 1st 24 hours, then q4 thereafter.
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