OSPITAL NG MAYNILA MEDICAL CENTER Department of Ophthalmology Name: CALDERON, CATALINA Age/Sex: 74/F Address: 2512 B Gomez St.,Sta. Ana, Manila Date of Admission: September 13, 2007; 10:40am Admitting Diagnosis: CSI OU Physicians-in-charge: Drs. Reyes/Mateo/Corpuz 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: 6 months prior to consult, while washing patient accidentally splashed Clorox on her right eye. She immediately flushed it with tap running water. There was excessive tearing and eye pain. Persistence of symptoms prompted consult at OMMC, diagnosis was unrecalled. No medications were given. Patient was lost to follow up. 2 months prior to consult, patient experienced itchiness of the left eye with concomitant blurring of vision. No excessive lacrimation was observed. Persistence of blurring of vision prompted consultation thus the subsequent admission. Past Medical History: (-) DM, HPN, BA, PTB Family History: (+) BA, PTB (-) DM, HPN Previous Eye History: None Personal and Social History: nonsmoker, non-alcoholic beverage drinker, coffee drinker 2x/day 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 Physical Examination: VS: HR: 80 bpm RR: 20 Temp: 36.9 C BP 120/80 General: Conscious, coherent, not in cardiorespiratory distress HEENT: anicteric sclerae, pink palpebral conjunctivae, no tonsillopharyngeal congestion, no cervical lymphadenopathy Visual Acuity OD OS Refraction OD OS External Eye Exam 2-3 mm PERTL PPC 20/40 20/40 Objective Rx N/A N/A SC PH NIPH NIPH Subjective Rx CC SC 7-1 7 Previous RX J CC Hospital No: 1072152
(+) toothpaste sign
Slit Lamp Clear (-) uptake HHhhhH Clear (-) uptake
1x Applanation Tonometry: OD: 15 OS: 16
Fundoscopy OD: (+) faint ROR, hazy media OS: (+) faint ROR, hazy media Chest and Lungs: Symmetric chest expansion, no retractions, clear breath sounds Heart: Adynamic precordium, normal rate, regular rhythm, no murmurs Abdomen: flat, normoactive bowel sounds, soft, nontender, no organomegaly Extremities: grossly normal, no edema, no cyanosis, full and equal pulses Assessment: Plan: CSI, OU
Course in the wards: Patient was admitted under the service of Drs. Reyes/Mateo/Corpuz. Vital signs were monitored every 4 hours. Consent for admission was secured. She was on lowsalt, low fat diet. She was given Imidapril 5mg/tab, 1 tab OD, Captopril 25mg/tab, 1 tab SL prn for BP> 160/90 and Moxifloxacin (Vigamox) E/S 1 gtt to OU TID. She was scheduled for Phacoemulsification with PCIOL, OD under local anesthesia under the service of Drs. Reyes/ Brucelas/ Daffon at 1130 hours. Consent for operation was secured. She may have light breakfast at 6:00am then NPO thereafter. Full facial, oral, body hygiene prior to operation was requested. Medications given were: Tropicamide E/S and Diclofenac E/S, 1 gtt to OS q10minutes to start at 5:00am, and Acetazolamide 250mg tab, 2 tabs 2 hours prior to operation.