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Palma6hrs by dredwardmark

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									OSPITAL NG MAYNILA MEDICAL CENTER Department of Ophthalmology Name: Palma, Benjamin Age/Sex: 54/M Address: 2221 Narra St. Tondo Manila Date of Admission: September 18, 2007; 11:30 am Admitting Diagnosis: CPSM OD Physicians-in-charge: Drs. Reyes/Mateo/Corpuz Clerk-in-charge: Patayan/ Raagas/ Reloj Patient’s 6-Hour History This is a case of a 54-year-old female from Tondo, Manila who came in due to blurring of vision, OD. History of Present Illness: 2 weeks PTC, patient noticed blurring of vision OD, described as cloudiness of vision not associated with eye pain, excessive lacrimation and LOC. There was persistence of blurring of vision hence consult. Past Medical History: (-) DM, HPN, asthma, allergies, TB Family History: (+) DM - mother, (+) HPN – father; (-) asthma, allergies, TB Previous Eye History: none Personal and Social History: Previous smoker (stopped since 1983), occasional 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 20/200 +1 20/20-1 Objective Rx N/A N/A PH 20/125 +2 20/80 Subjective Rx CC SC 20/400 5 Previous RX J CC Hospital No: 1460168

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 visualized. OS: (+) ROR, CM, DDB, CDR 0.3 AVR 2:3 Assessment: Plan: CPSM OD

For admission

Course in the wards: Patient was admitted under the service of Drs. Reyes/Mateo/Corpuz. Vital signs were monitored every 4 hours and are stable. Input and output monitoring every shift. Diet is as tolerated. 1st hospital day,


								
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