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OSPITAL NG MAYNILA MEDICAL CENTER Department of Ophthalmology Name: ABUEL, LICANDRO Age/Sex: 66/M Address: 2043 c. Modesto St., San Andres Bukid, Manila Date of Admission: September 17, 2007; 1:45 pm Admitting Diagnosis: CSHM OD; CSI OS Physicians-in-charge: Drs. Reyes/Mateo/Daffon Clerk-in-charge: Patayan/ Raagas/ Reloj Patient’s 6-Hour History This is a case of a 66-year-old female from Sta. Ana, Manila who came in due to progression of blurring of vision, OD. History of Present Illness: 2 years PTC, patient noticed blurring of vision, OD. Consult was done in a government hospital in Aklan. Patient was prescribed with an unrecalled eye solution. 1 year PTC, patient could not read anymore with OD, there was no associated pain. Patient also had headache. Progression of signs and symptoms prompted consult. Past Medical History: (-) DM, HPN, asthma, allergies, TB Family History: (-) DM, HPN, asthma, allergies, TB Previous Eye History: 5-year use of corrective lens, unrecalled refraction Personal and Social History: smoker of 10 pack years but has stopped smoking 10 years PTC, non-alcoholic beverage drinker Review of Systems: Constitutional: No weight loss or gain, no irritability, no chills, no fever Skin: No unusual pigmentation, no itchiness HEENT: No ear discharge, no hoarseness Respiratory: No increased respiratory effort, no cough, no hemoptysis Cardiovascular: No easy fatigability, no complaint of chest pain, no palpitations GIT: No diarrhea, no melena, no hematochezia GUT: No hematuria, no dysuria Hematology: No poor wound healing, no easy bruisability Neurology: No seizure, no tremors, no loss of consciousness Visual Acuity OD OS Refraction OD OS External Eye Exam 2-3 mm PERTL PPC HM 20/160 Objective Rx N/A N/A SC PH CC SC 20/80 Subjective Rx 16 Previous RX J CC 16 Hospital No: 1440933 PPC anicteric sclerae EOM Slit Lamp Clear (-) uptake HHhhhH Clear (-) uptake HM III 1x 6x 1x 1x 6x 1x Fundoscopy OD: (-) ROR, other structures not seen OS: (+) ROR, HM, other structures not seen Assessment: Plan: CSHM, OD: CSI, OS For admission Course in the wards: Patient was admitted under the service of Drs. Reyes/Mateo/Daffon. Vital signs were monitored every 4 hours. Consent for admission was secured. Diet is as tolerated. Patient was prescribed with Moxifloxacin E/S 1 gtt to OU q6. She was scheduled for ECCE with PCIOL, OU under local anesthesia under the service of Drs. Mateo/ Brucelas/ Daffon/Sumajit/Samaniego/Corpuz/Gapay.
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