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					OSPITAL NG MAYNILA MEDICAL CENTER Department of Ophthalmology

Name: Invenzur, Loreto Hospital No: 1723963 Age/Sex: 29/M Address: Hipodromo St. Sta. Mesa, Manila Date of Admission: August 20, 2007 Admitting Diagnosis: Corneoscleral Laceration with Iris Prolapse, OS Physicians-in-charge: Drs. Reyes/Mateo/Samaniego Clerks in charge: Ybanez/Yeban/Zamora

CLINICAL ABSTRACT This is a case of a 29-year old male, who came in due to blurring of vision on the left eye. History of Present Illness: 6 hrs prior to admission, patient was mauled and was hit on the temporoparietal area with a bottle. He was also punched on the left eye. Blurring of vision on the left eye prompted consult at OMMC ER and was subsequently admitted. Past Medical History: Patient has bronchial asthma since childhood and was previously hospitalized due to bronchopneumonia. No history of hypertension and diabetes. No food and drug allergies. Family Medical History: With family history of hypertension (father). With history of diabetes on both sides. With history of bronchial asthma (fatherside, grandfather and uncle). Denies other heredofamilial disease. Previous Eye History: Denies any eye illness and has no previous eye operation Personal/Social History: 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= 73 RR=20 T= 36.5 C BP= 110/70 mmHg HEENT: normocephalic, anicteric sclerae, no tonsillopharyngeal congestion, no cervical lymphadenopathy, no neck vein distention, no neck mass Visual Acuity: OD: 20/50, -3 NIPH OS: 20/200 NIPH
External Eye Exam
(+) papillae

PERTL 2-3mm

PPC
PPC PPC

hyperemic

Blackish body

hyperemic Erythema

EOM

Full and equal

Funduscopy OD: (+) ROR, CM, DDB, CDR 0.3, AVR 2:3, (-) H/E OS: (+) ROR, CM, DDB, CDR 0.3, AVR 2:3, (-) H/E Slit Lamp

(-) dye uptake

no opacity

No opacity

1x

6x

1x

1x

6x

1X

AT: OD: OS: NLDI: OS: OD:

Iris Prolapse Laceration

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: Corneoscleral Laceration with Iris Prolapse, OS Plan: Patient was admitted to Ophthalmology Ward Rm 221 Charity Ward under the service of Dr. Reyes, Mateo and Samaniego. Consent for admission was secured. He was placed on NPO for possible direct OR. His vital signs were monitored 4 hourly and was given the following medications; Penicillin G 6 million units loading dose, then 4 million units through IV every 6 hours, Chloramphenicol 500 mg TIV every 6 hours and Moxifloxacin E/S, 1 gtt to OS every 15 minutes. An eye shield was placed on left eye.

OSPITAL NG MAYNILA MEDICAL CENTER Department of Ophthalmology

Name: Invenzur, Loreto Hospital No: 1723963 Age/Sex: 29/M Address: Hipodromo St. Sta. Mesa, Manila Date of Admission: August 20, 2007 Date of Discharge: August 23, 2007 Admitting Diagnosis: Corneoscleral Laceration with Iris Prolapse,OS Final Diagnosis: S/P repair of Corneal laceration Physicians-in-charge: Drs. Reyes/Mateo/Samaniego Clerks in charge: Tuble/Vasquez/Velasco

Patient’s Discharge Summery This is a case of a 29-year old male, who came in due to blurring of vision on the left eye. History of Present Illness: 6 hrs prior to admission, patient was mauled and was hit on the temporoparietal area with a bottle. He was also punched on the left eye. Blurring of vision on the left eye prompted consult at OMMC ER and was subsequently admitted. Past Medical History: Patient has bronchial asthma since childhood and was previously hospitalized due to bronchopneumonia. No history of hypertension and diabetes. No food and drug allergies. Family Medical History: With family history of hypertension (father). With history of diabetes on both sides. With history of bronchial asthma (fatherside, grandfather and uncle). Denies other heredofamilial disease. Previous Eye History: Denies any eye illness and has no previous eye operation Personal/Social History: 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= 73 RR=20 T= 36.5 C BP= 110/70 mmHg HEENT: normocephalic, anicteric sclerae, no tonsillopharyngeal congestion, no cervical lymphadenopathy, no neck vein distention, no neck mass Visual Acuity: OD: 20/50, -3 NIPH OS: 20/200 NIPH

External Eye Exam
(+) papillae

PERTL 2-3mm

PPC
PPC PPC

hyperemic

Blackish body

hyperemic Erythema

EOM

Full and equal

Funduscopy OD: (+) ROR, CM, DDB, CDR 0.3, AVR 2:3, (-) H/E OS: (+) ROR, CM, DDB, CDR 0.3, AVR 2:3, (-) H/E Slit Lamp

(-) dye uptake

no opacity

No opacity

1x

6x

1x

1x

6x

1X

AT: OD: OS: NLDI: OS: OD:

Iris Prolapse Laceration

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: Corneoscleral Laceration with Iris Prolapse, OS Course in the Wards: Patient was admitted to Ophthalmology Ward Rm 221 Charity Ward under the service of Dr. Reyes, Mateo and Samaniego. Consent for admission was secured. He was placed on NPO for possible direct OR. His vital signs were monitored 4 hourly and was given the following medications; Penicillin G 6 million units loading dose, then 4 million units through IV every 6 hours, Chloramphenicol 500 mg TIV every 6 hours and Moxifloxacin E/S, 1 gtt to OS every 15 minutes. An eye shield was placed on left eye. The patient was directed to OR few hours prior to his admission. Post-operative orders were: DAT if patient is fully awake. VS monitoring q 15 minutes for the 1st hour, q 30 for the 2nd hour and q 1 hour thereafter. Medications given were: Mefenamic Acid 500mg cap q 6 prn for pain, Atropine E/S TID to OS, Prednisolone acetate E/S 1 gttt to OS q 4, Tranexaminc Acid 500mg cap TID x 3 days. The previous medications were comtinued. The patient was for possible B-scan, OS On the 2nd hospital day, VA: OD=20/25+5, OS 20/200. Medications were continued. Eye patch was placed at all times. Hold eye drops. On the 3rd hospital day, the VA: OD=20/20, OS 20/200  20/100. Medications were continued. The patient was referred to External Disease consultant. The patient was advised to go home if after 2 days of IV meds, the fundoscopic findings is normal. Medications given were: Moxifloxacin E/S, 1 gtt to OS q 4, Prednisolone acetate E/S 1 gttt to OS q 4, Atropine E/S TID to OS TID and Eye patch to OS at all times and Chloramphenicol 500 mg TIV every 6 hours and Pen G. On the 4th hospital day, VA OD: 20/20-2  20/20, OS: 20/70  20/30-3. Indirect fundoscopy: OS: (+) ROR, SHM, DDB, CDR 0.3, AVR 2:3 (-) H/E. The patient was for discharge. IV meds were shifted to oral. Amoxiate 500mg/tab 1 tab TID x 7 days and Mefenamic Acid 500mg cap QID prn for pain in ful stomach. To come back at Ophtha-OPD Tuesday, Aug.28, 2007.


				
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