OSPITAL NG MAYNILA MEDICAL CENTER Department of Ophthalmology Name: Cepe, Winnie Age/Sex: 19/M Address: 1083 Int 83, Mendiola Otis, Manila Date of Admission: September 10, 2007 Admitting Diagnosis: Steroid induced / Post Uveic Cataract, OD; NLDO, Right Physicians-in-charge: Drs. Reyes/Mateo/Sumajit-Salamida Clerk-in-charge: Viar/ Villanueva/Villarama Patient’s 24-Hour History This is a case of 19 year old male from Paco, Manila previously diagnosed with Chronic Uveitis, OU; Post – uveic, Cataract, OU (OD>OS); NLDO, OD History of Present Illness: 1 year and 4 months PTA, the patient had eye pain with discharge, associated with redness and tearing, which resolves spontaneously. 1 year and 3 months PTA, the patient experienced blurring of vision of the right eye, not associated with redness, eye pain, or eye discharge. This prompted the patient to consult at a local Clinic from which he was given Ciprofloxacin (Ciloxan) eye solution every 4 hours and Prednisolone (Pred Forte) eye solution every hour, but with poor compliance. The blurring of vision persisted. 1 year PTA, the patient returned to the said Clinic due to the redness of the right eye and blurring of vision. He was given Polymyxin+Neomycin+Dexamethasone (Maxitrol) eye solution every 6 hours, and was advised to follow up after 1 month. 11 months PTA, eye redness was resolved, but still with blurring of vision. The patient returned for follow-up as advised. He was prescribed with Prednisolone and PND eye solution was continued. The blurring of vision persisted. 3 months PTA, he noted blurring of vision of the left eye, associated with frontal headache. There was no redness, no eye pain or discharge. This prompted the patient to consult at our institution. Laboratory examinations were requested and he was advised to come back with results. 1 month PTA, the patient came back for follow-up, and was admitted and scheduled for operation. The operation was deferred due to NLDO, OD. He was prescribed with Sulfacetamide eye solution 1 gtt to OD q 4 and Cloxacillin 500mg/cap 1 cap q 6 for 7 days. Warm compress to the affected eye and lacrimal massage was also advised. He was instructed to go home and to return for follow-up. The patient came back for follow-up and was subsequently admitted. Past Medical History: s/p appendectomy, OMMC, October 2006 no HPN, DM, BA, allergies, PTB Family History (+) HPN to parents The patient denies any heredo-familial diseases Previous Eye History: No previous eye surgery, or trauma. The patient don’t wear eye glasses Personal/Social History: The patient is a non-smoker and an occasional alcoholic beverage drinker. Review of Systems: Constitutional: no weight loss, no irritability, no chills, no fever Skin: No unusual pigmentation, no itchiness HEENT: no headache, no nasal discharge, no ear discharge, no hoarseness Respiratory: no increased respiratory effort, no cough, no hemoptysis Cardiovascular: no cyanosis, no chest pains, no palpitations, no easy fatigability, no orthopnea, no PND GIT: no diarrhea, no melena, no hematochezia GUT: no hematuria, no oliguria, no dysuria Hematology: no poor wound healing, no easy bruisability Neurology: no seizure, no tremors, no loss of consciousness Hospital No: 1442954 Physical Examination: VS: 65 bpm RR: 15 cpm Temp 36.5 C BP 100/60 General: conscious, coherent, not in cardiorespiratory distress HEENT: anicteric sclerae, pink palpebral conjunctivae, no nasoaural discharge, no tonsillopharyngeal congestion, no cervical lymphadenopathy Visual Acuity OD OS Refraction OD OS External Eye Exam SC CF at 2 ft 20/100 Objective Rx N/A N/A PH NIPH NIPH CC n/a n/a Subjective Rx SC CC N/a n/a Previous RX Refraction n/a n/a Reactive to light 2-3 mm PPC PPC Reactive to light Anicteric sclera EOM Slit Lamp Clear HHhhhH Synechiae Clear PSC ++ PSC ++ touch 3x Applanation Tonometry: OD: 12 OS: 13 touch touch 3x touch Fundoscopy OD: (+)ROR, HM, (+) posterior subcapsular cataract, other structures not seen OS: (+)ROR, HM, (+) posterior subcapsualr cataract, DDB, CDR 0.3, AVR 2:3, (-) hemorrhage Chest and Lungs: Symmetric chest expansion, no retractions, clear breath sounds Heart: Adynamic precordium, 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: Steroid induced / Post Uveic Cataract, OD; NLDO, Right Plan: For admission For DCR (GA) Course in the Wards: Upon admission, the patient was admitted to OMMC Ophtha ward 217 under the services of Drs. Reyes / Mateo/ Sumajit. Consent for admission was secured. Medications given include Sulfacetamide + Prednisone eye solution 1 gtt to OU every 1 hour. Vital signs were monitored every four hours. VA: OD: CF at 2 ft NIPH, OS: 20/100 NIPH; AT: OD: 12, OS: 13. Patient’s vital signs were stable with occasional bradycardia. On the 1st hospital day, patient’s vital signs are stable. Visual Acuity OD: 6/200 NIPH and OS: 20/200 20/100. Present management and other medications are continued. The patient was scheduled for Dacryocystorhinostomy under general anesthesia under the services of Drs. Reyes, Ang, Brucelas, Daffon. 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.
Pages to are hidden for
"cepe winnie 24h"Please download to view full document