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OSPITAL NG MAYNILA MEDICAL CENTER Department of Ophthalmology Name: Torres, Allan Age/Sex: 29/M Address: 2214 Rubi Street, San Andres Bukid, Manila Date of Admission: September 12, 2007 Admitting Diagnosis: T/C Retrobulbar hemorrhage Physicians-in-charge: Drs. Reyes/Mateo/Sumajit-Salamida Clerk-in-charge: Viar/ Villanueva/Villarama Patient’s 24-Hour History This is a case of a 29-year-old male from Manila, who came in due to swelling of left eye. History of Present Illness: Eight hours prior to admission patient was having an argument with his cousin after a drinking spree. Patient was punched on the face by his cousin causing swelling of his left eye and loss of vision, pain. Persistence of above symptoms hence admission Past Medical History: (+) Hypertensive; HBP: 140/100 Family History (+) HPN - parents Previous Eye History: None Personal/Social History: Smoker Occasional alcoholic beverage drinker Review of Systems: Constitutional: no weight loss, no irritability, no chills, no fever Skin: No unusual pigmentation, no itchiness HEENT: no nasal discharge, no ear discharge, no hoarseness Respiratory: no increased respiratory effort, no cough, no hemoptysis Cardiovascular: no cyanosis GIT: no diarrhea, no melena, no hematochezia GUT: no hematuria Hematology: no poor wound healing, no easy bruisability Neurology: no seizure, no tremors, no loss of consciousness Physical Examination: VS: HR 72 bpm RR 18 cpm Temp 36.6 C BP: 130/90 General: conscious, coherent, not in cardiorespiratory distress HEENT: anicteric sclerae, pink palpebral conjunctivae, no nasoaural discharge, no cervical lymphadenopathy Visual Acuity OD OS Refraction OD OS External Eye Exam AS Reactive to light 2-3 mm Not Reactive to light, mid dilated, RAPD Swelling Contusion Hematoma SC 20/50 NO light perception Objective Rx N/A N/A PH NIPH 20/200 Subjective Rx Previous RX CC SC CC Refraction UBP: 120/80; No medications taken Hospital No: 1735099 PPC Subconjunctival hemorrhage, proptosed, resistant to retropulsion, cheimosis EOM Slit Lamp Clear (-) uptake HHhhhH No opacity (+) uptake No opacity 1x Applanation Tonometry: OD: 12 OS: 6 6x 1x 1x 6x 1x Fundoscopy (with dilation) OD: (+)ROR OS: (+)ROR, CM, DDB, CDR 0.3 AVR 2:3 (-)H/E HERTEL’S: 12--- 115 ----22 Chest and Lungs: Symmetric chest expansion, no retractions, clear breath sounds Heart: Adynamic precordium, bradycardic, regular rhythm, no murmurs Abdomen: flabby, normoactive bowel sounds, soft, nontender, no organomegaly Extremities: grossly normal, no edema, no cyanosis, full and equal pulses Assessment: Contussion Hematoma , periorbital area, OS DES OS, Traumatic Optic Neuropathy Compartment Syndrome Plan: For Admission Course in the wards: Patient was admitted under the service of Drs. Reyes/Mateo/Daffon. Patient was put on regular diet. Vital signs were monitored every 4 hours. IVF was started PLR 1 L x KVO. Laboratory requested were: CBC with PC, Urinalysis, CXR-PA; Skull AP/L, 12-L ECG, FBS, CT scan, cranial to include orbits, axial and coronal views, B-scan, OS. Medications given were: 1. Dexamethasone Sodium Phosphate 53 mg TIV as loading dose (0.75 mkd), then 23.33 mg every 6 hours TIV for 24-48 hours once CXR-PA is normal. 2. Hypromellose (Genteal) E/S 1 gtt to OS BID 3. Tobramycin E/S 1 gtt to OS q4 4. Carbomer E/G 1 gtt to OS BID Initial CXR-PA: Magnified Cardiac shadow. Skull X-ray: negative for fractures, ECG: early rep, NSSTWE. On his 1st hospital day, patient underwent B-scan with the following findings: vitreous clear and attached retina. Consent for Lateral Canthotomy, OS was secured. Lateral Canthotomy and cantholysis OS was done. He was given Amoxicillin 500mg/cap, 1 cap TID for 7 days, Mefenamic Acid 500mg/cap, 1 cap QID prn for pain on full stomach and Tobramycin (Tobrex) ointment TID on the affected area. Patient was referred to IM for co-management of hypertension. Clonidine 75mcg tab was given through sublingual route. On his 2nd hospital day, visual acuity in OD is 20/20-4; OS can detect hand movement with poor light perception but with fair light projection. Left eye movement was restricted halfway through in intraocular muscle movement test done. Vital signs were stable. Review of medications: 1. Dexamethasone Sodium Phosphate 23.33mg q6 TIV 2. Hypromellose E/S 1 gtt to OS BID 3. Tobramycin E/S 1 gtt to OS q4 4. Carbomer E/G 1 gtt to OS BID 5. Tobradex E/O 1 gtt to OS TID 6. Amoxicillin 500mg/ cap, 1 cap q8 for 7 days 7. Mefenamic Acid 500mg/cap, 1 cap as needed for pain on full stomach Eye taping was continued so with warm compress to the left eye. Patient was permitted to go out on pass for CT scan with ophtha PGI via ambulance conduction. Subsequent referral to service consultant was done once CT scan plates were in. Patient was referred to ENT for evaluation and co-management. On his 3rd hospital day, vital signs were stable. Patient was referred to Dr. Santiago via SMS wherein repair of floor and medial wall fractures with titanium mesh was advised once with funds. Eye patch to the affected area was continued so with the application of warm compress. Medications were: 1. Dexamethasone Sodium Phosphate 11.5mg q6 TIV for 1 week, then decrease to 5.75 for another week; 2.5mg for 1 week, BID for 1 week then discontinue 2. Tobramycin E/S 1 gtt to OS q4 3. Carbomer E/G 1 gtt to OS BID 4. Tobradex E/O 1 gtt to OS TID 5. Amoxicillin 500mg/ cap, 1 cap q8 for 7 days 6. Mefenamic Acid 500mg/cap, 1 cap as needed for pain on full stomach On his 4th hospital day, left eye has fair light projection on the temporal area and at the center. IV Dexamethasone 11.5mg q6 TIV was continued for 6 more days to complete 7 days then taper to 5.75mg q6 TIV for 1 week. Tobramycin + Dexamethasone (Tobradex) E/O to OS TID was advised. Eye patch to OS at all times was advised except when instilling medications. On his 5th hospital day (September 17, 2007), vital signs were stable. Patient was referred to IM for CP clearance.
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