guiao 6 hr hx by dredwardmark


									OSPITAL NG MAYNILA MEDICAL CENTER Department of Ophthalmology

Name: Guiao, April Age/Sex: 20/F Address: 147-C Herbosa St., Ext. Tondo, Manila Date of Admission: August 23, 2007 Date of Discharge: Admitting Diagnosis: Traumatic Cataract Corneal Leukoma, OD Discharge Diagnosis: Physicians-in-charge: Drs. Reyes/Mateo/ Samaniego Clerks in charge: Tuble/Vasquez/Velasco

Hospital No: 1448160

6 hour history This is a case of a 20 year old female, who came in due to blurring of vision of the right eye. History of Present Illness: 15 years prior to admission, patient was hit by a knife on her right eye, causing an incision. The incision was sutured at Jose Reyes Medical Center. The procedure produced a scar on the lower half of the cornea, OD. Patient had blurred vision since then, can only see counting fingers. The symptom worsened until only light can be perceived by her right eye, hence consult and subsequent admission. Past Medical History: (-) HTN, DM, BA, Allergy, PTB Family Medical History: Denies any heredofamilial diseases Personal/Social History: Non Smoker and 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 dizziness, no tinnitus, no epistaxis, no neckpain, no dysphagia, no hoarseness Respiratory: no difficulty of breathing, no cough, no colds, no hemoptysis Cardiovascular: no chest pains, no orthopnea GIT: no abdominal pain, no change in bowel movements, no melena, no hematochezia GUT: no dysuria, no oliguria, no hematuria Endocrinology: no polydipsia, polyphagia, 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, with alcoholic breath Vital Signs: HR= 88 RR=16 T= 36.6 C BP= 90/60 mmHg HEENT: normocephalic, anicteric sclerae, no tonsillopharyngeal congestion, no cervical lymphadenopathy, no neck vein distention, no neck mass Visual Acuity: OD: LP OS: 20/20

External Eye Exam




Anicteric Sclerae


Full and equal

Funduscopy OD: (-) ROR, other structures cannot be appreciated OS: (+) ROR, CM, DDB, CDR 0.3, AVR 2:3, (-) H/E Slit Lamp

clear uptake

(+) opacity Clear uptake







AT: OD: 12 OS: 14

CHEST and LUNGS: symmetrical chest expansion, clear breath sounds HEART: no precordial bulge, normal rate, regular rhythm ABDOMEN: flat, soft, non-tender, normoactive bowel sounds EXTREMITIES: no pallor, no cyanosis, full and equal pulses Assessment: Traumatic Cataract with anterior adherent corneal leukoma Plan: For admission For I & A with Pupilloplasty, OD

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