OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF OPHTHALMOLOGY Patient’s Name: CAGURUNGAN, Magdalena Address: 4096 Sto. Cristo, Tondo, Manila Age/Sex: 53 year old/ Female Date of Admission: July 17, 2008 Admitting Diagnosis: Post-traumatic Cataract Physician–in-charge: Dr. Reyes/ Sumajit/Gapay Clerks-in-charge: Fabian/Ilarde/Inlges/Item/Junsay Hospital No: No.1498947 Room: 217 6-HOUR HISTORY This is a case of a 53 y/o female who came in due to blurring of vision of the right eye after a history of trauma HPI: 10 years PTA, patient sought consult at a unrecalled private clinic due to BOV of the right eye after a history of trauma. Patient was advised for operation but did not push through due to personal reasons. Hours PTA, persistence of above signs and symptoms prompted consult and was subsequently admitted. Past Medical History: (-) HPN (-) DM (-) Asthma (-) allergies (-) Kidney disease (-) PTB (+) Previous hospitalizations: operated on Right Eye when she was 10 years old Family History: (+) DM- Sibling (-) HPN Previous Eye History: Wore eyeglasses for 2 years Personal / Social History: Unemployed, non-smoker, non-alcoholic beverage drinker Physical Examination: Gen: Awake, alert, NICRD VS: BP: 130/90 HR: 80 RR: 16 Temp: 36.5 Skin: good skin turgor, C/L: Symmetric chest expansion, no retractions, clear breath sounds th Heart: Adynamic precordium, PMI at 5 ICS RMCL, no heaves, no thrills, no murmurs Abdomen: flabby, non distended, NABS, soft, nontender Extremities: grossly normal, full and equal pulses, no edema, no cyanosis Visual Acuity: OD: OS: sc HM, GLP 20/40 ph 20/32 cc External Eye Exam: PERTL 2-3mm pink palpebral conjunctiva PERTL 2-3mm Pink palpebral conjunctiva Anicteric sclerae (+) opacity Anicteric sclerae Extraocular muscles: Fundoscopy: OD: (-) ROR, inner structures can not be assessed OS: (+) ROR, CM, DDB, CDR 0.3, AVR 2:3, (-)HIE Slit lamp Assessment: POST-TRAUMATIC CATARACT, OD Plan: For admission Patient may be admitted to room 217, Charity ward under the service of Drs. Reyes/ Sumajit/ Gapay. Patient may have DAT. Consent for admission was secured. Vital signs and Input & Output was monitored and recorded. Medications were: 1. Moxifloxacin (Vigamox) E/S; 1 gtt OU q4 2. Captopril 25mg/tab; 1 tab for BP >140/100 Initial VA, AT and NLDI c/o RIC. 6 and 24-hour history c/o CIC Pre-operative Orders: Please schedule patient for ECCE w/ PCIOL, OD under LA under the service of Drs. Reyes/Sumajit/Gapay at 0130hrs. Please secure consent for surgery May have light breakfast at 6am then NPO Full facial/oral/ body hygiene prior to OR MEDS: 1. Acetazolamide 250mg/ tab; 2 tabs 2 hour prior to or 2. Tropicamide eye drops; 1 drop to OD q 10 min to start at 5am c/o COD. 3. Diclofenac eye drops 1 drop to OD q 10 min to start at 5am c/o COD.
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