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CONCEPCION 24h

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					OSPITAL NG MAYNILA MEDICAL CENTER Department of Ophthalmology Name: CONCEPCION, Enofre Age/Sex: 73/F Address: 2453 Radium St., San Andres Bukid, Manila Date of Admission: September 10, 2007 Admitting Diagnosis: CSHM, OU Physicians-in-charge: Drs. Reyes/Mateo/Sumajit-Salamida Clerk-in-charge: Viar/ Villanueva/Villarama Patient’s 24-Hour History eyes. This is a case of a 73-year-old female from San Andres Bukid who came in due to blurring of vision of both . Hospital No: 1454496

History of Present Illness: 2 years prior to admission, the patient started noticing blurring of vision on the right eye associated with tearing and photophobia. No consult was done and no medications were taken. 1 year prior to admission, there was blurring of vision of the left eye and p[rogression of the blurring of vision on the right. Still, no consult was done and no medications taken or applied. 6 months prior to admission, the progression of the blurring of vision prompted consult with a private ophthalmologist. Surgery was contemplated and laboratory work-up was done. Patient was diagnosed to have DM with FBS 8.12. Surgery was deferred and patient was referred to our institution. Patient was diagnosed with CSHM, OD and advised surgery, hence the subsequent admission. Past Medical History: Patient is a known diabetic for 5 months maintained on Glibenclamide OD for 2 months with good compliance. Patient has had hypertension for 10 years and has been poorly compliant to metoprolol for 4 years. Family History (+) HPN (+) DM (-) other heredofamilial diseases Previous Eye History: Prescribed with eyeglasses for 10 years and stopped 1 year prior to admission. Personal/Social History: Patient is a non-smoker and does not drink alcoholic beverages Review of Systems: Constitutional: no weight loss, no irritability, no chills, no fever Skin: No unusual pigmentation, no itchiness HEENT: no nasal discharge, no ear discharge, no hoarseness Respiratory: no increased respiratory effort, no cough, no hemoptysis Cardiovascular: no cyanosis GIT: no diarrhea, no melena, no hematochezia GUT: no hematuria Hematology: no poor wound healing, no easy bruisability Neurology: no seizure, no tremors, no loss of consciousness Physical Examination: VS: 78 bpm RR: 16 cpm Temp 36.5 C BP 120/80 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 SC CF at 3 ft CF at 3 ft PH NIPH NIPH CC SC CC J: unable to read 1st line at 14in J: unable to read 1st line at 14in Refraction

Refraction OD OS

Objective Rx N/A N/A

Subjective Rx

Previous RX

External Eye Exam Reactive to light 2-3 mm

PPC

PPC

Reactive to light Anicteric sclera EOM

Slit Lamp

Clear (-)uptake

HHhhhH Hypermature

clear (-)uptake

HM

1x Applanation Tonometry: Fundoscopy OD: (-) ROR OS: (-) ROR OD: OS:

6x

1x

1x

6x

1x

Fundoscopy (dilated) 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: Plan: CSHM, OU (OD > OS)

For admission

Course in the wards: Patient was admitted under the service of Drs. Reyes/Mateo/Sumajit-Salamida. Patient was put on low salt, low fat diet. Vital signs were monitored every 4 hours. Diagnostics requested are CBC with PC, UA, CXR-PA, 12-L ECG, CT, BT FBS. Medications given were: 1. Ciprofloxacin E/S 1 gtt to OU 4x a day 2. Imidapril + HCTZ tab once a day 3. Nifedipine 5 mg SL prn BP >160/100 4. Simvastatin 4g tab ½ tab at HS 5. Glibenclamide once a day 6. Metformin 500 mg tab BID Visual Acuity OD: CF at 3 ft, OS: CF at 3 ft, AT OD: 18 OS: 18. NLDI OS: patent, OD: patent. Patient’s vital signs are stable. On the 1st hospital day, patient’s vital signs are stable. Visual Acuity OD: CF at 3 ft and OS: CF at 3 ft. Present management and other medications are continued. The patient was scheduled for phacoemulsification with PCIOL, OD on local anesthesia under the services of Drs. Reyes, Mateo, Sumajit, Corpuz. 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 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.


				
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