OSPITAL NG MAYNILA MEDICAL CENTER Department of Ophthalmology Name: BASCON, EMILIANO Age/Sex: 74/M Address: Room 213 Sambahayan Rawis Bldg I, Tondo, Manila Date of Admission: September 17, 2007; 2:20 pm Admitting Diagnosis: CSM OU Physicians-in-charge: Drs. Reyes/Mateo/Daffon Clerk-in-charge: Patayan/ Raagas/ Reloj Patient’s 6-Hour History This is a case of a 74-year-old female from Sta. Ana, Manila who came in due to progression of blurring of vision. History of Present Illness: 2 years PTC, patient had blurring of vision with no other associated symptoms. No consult was done, no meds taken. Progression of blurring of vision prompted consult. Past Medical History: (-) DM, HPN, BA, PTB; (+) kidney disease Family History: (-) DM, HPN Previous Eye History: None Personal and Social History: nonsmoker, 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 SC 20/100 -2 CF 3 meters Objective Rx N/A N/A PH 20/50 - 2 NIPH Subjective Rx Previous RX CC SC J CC Hospital No: 1452206
anicteric sclerae EOM
Slit Lamp Clear (-) uptake HHhhhH Clear (-) uptake
Fundoscopy OD: (+) ROR, hazy media OS: (+) ROR, hazy media Assessment: Plan: CSM, OU
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 Tobramycin E/S 1 gtt to OU QID. She was scheduled for ECCE with PCIOL, OU under local anesthesia under the service of Drs. Mateo/ Brucelas/ Daffon/Sumajit/Samaniego/Corpuz/Gapay.