OSPITAL NG MAYNILA MEDICAL CENTER Department of Ophthalmology Name: COSILIT, ELSID Age/Sex: 11MO/M Address: 2310, Adriatico, Malate, Manila Date of Admission: September 10, 2007 Admitting Diagnosis: Preseptal cellulitis, OS Final Diagnosis: Preseptal Cellulitis, resolved Physicians-in-charge: Drs. Reyes/Mateo/Sumajit-Salamida Clerk-in-charge: Viar/ Villanueva/Villarama Patient’s Discharge Summary This is a case of an 11-month old male from Malate, Manila who was brought in due to swelling of the left upper lid. History of Present Illness: 5 days prior to admission, the patient was noted to have a pustule on the left temporal area. The pustule was noted to gradually enlarge. Patient was also noted to have fever (38 C). No consult done and no medications taken. 3 days prior to admission, there was progression of the pustule to a carbuncle. Patient also had swelling of the left upper eyelid. Patient still had febrile episodes. Consult was done at Ophtha-OPD of OMMC and patient was prescribed Paracetamol and Cloxacillin 250 mg/5 ml 2.5 ml every 6 hours. 1 day prior to admission, the carbuncle was noticed to have purulent discharge. Swelling of the eyelid progressed and patient had inability to open the left eye, thus prompting consult and subsequent admission. Past Medical History: Pre-natal: Patient was the 5th child of a 34-year-old G5P4 (4-1-0-4) housewife and 37 year-old father who works as a messenger. The patient’s mother reported no illnesses during gestation. Patient’s mother only had one prenatal checkup at about 4 months in gestation. No intake of multivitamins or ferrous sulfate or any drugs. No anti-tetanus shot given. Antenatal: Patient was born full-term, via NSVD at OMMC last October 6, 2006. There were no fetomaternal complications. Immunization: Patient’s mother claims that the patient has had no immunization. Feeding: Patient is bottlefed with Bonamil and consumes about 6 bottles of milk per day. Patient has no difficulty feeding. Growth and Development: Patient’s mother is unable to recall other developmental milestones. Patient is currently able to walk with support starting the age of 10 months. Behavior: Patient is responsive to people and surroundings and is not irritable. Past illnesses: Patient has had measles at 10 months of age. Family History No known heredofamilial diseases Review of Systems: Constitutional: no weight loss, no difficulty feeding, 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 Hospital No: 1733266 Date of Discharge: September 13, 2007 Physical Examination: General: conscious, active, not in cardiorespiratory distress, responsive to surroundings Vital Signs: Length: 74 cm Weight: 8 kg Head Circumference: 46 cm Chest Circumference: 45.5 cm Abdominal Circumference: 47.5 cm MidArm Circumference: 14.5 cm HEENT: anicteric sclerae, pink palpebral conjunctivae, no nasal discharge, no nasal septum deviation, no ear discharge, intact TM, no cervical lymphadenopathy Visual Acuity OD OS SC Central, steady, maintained Not assessed due to difficulty opening the eyes Objective Rx N/A N/A PH CC SC N/A N/A CC Refraction Refraction OD OS Subjective Rx Previous RX External Eye Exam Reactive to light 2-3 mm Not assessed PPC PPC Reactive to light Anicteric sclera EOM Fundoscopy OD: (+)ROR, CM, DDB, CDR 0.3 AVR 2:3 (-)H/E OS: unable to open eyes Chest and Lungs: Symmetric chest expansion, no retractions, clear breath sounds Heart: Adynamic precordium, normal rate, regular rhythm, no murmurs Abdomen: round, normoactive bowel sounds, soft, nontender Extremities: grossly normal, no edema, no cyanosis, full and equal pulses Assessment: Preseptal cellulitis, OS Plan: For admisión For referral to Pediatrics and ENT-HNS Department for co-management Course in the Wards: Patient was admitted under the service of Drs. Reyes/Mateo/Sumajit-Salamida. Patient was put on regular diet for age. D5IMB fluids was started. Vital signs were monitored every 4 hours. Diagnostics requested are CBC with PC, UA, CXR-AP/L, 15-L ECG. Medications given were: 1. Oxacillin 200mg q 6 TIV 2. Erythromycin E/S 1 gtt to OS TID Strict lid hygiene and warm compress were instructed. The patient was referred to Pediatrics and ENT-HNS for comanagement. On the 1st hospital day, patient vital signs were stable. Patient left eye can be opened, but still with upper eyelid edema. Medications were continued. IVF was shifted to heplock. On the 2nd hospital day, vital signs were stable. There was decreased swelling of the upper eyelid. Medications were continued. On the 3rd hospital day, IV medications were discontinued. Patient was advised to go home with the following medications: 1. Cloxacillin 250mg/5mL, 4mL q 6h x 7 days 2. Ascorbic Acid 1mL once daily Patient was scheduled to follow-up at OPD Ophthalmology Clinic on September 20, 2007.
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