geli ca by dredwardmark



Patient’s Name: GELI, James Address: Gate 10 Area B, Parola, Tondo, Manila Age/Sex: 13/M Date of Admission: July 23, 2008 Admitting Diagnosis: Contusion Hematoma (Periorbital Area) OD Abrasion, Lateral Canthal Area OD Traumatic Mydriasis OD Absolute Eye OD Physician–in-charge: Drs. Reyes/Sumajit/Samaniego/Ibasco/Tormon Clerks-in-charge: Fabian/Ilarde/Inlges/Item/Junsay

Hospital No: No. 1863498 Room: 221

CLINICAL ABSTRACT This is a case of a 13 year old male who came in due to pain on the right eye. HPI: One day PTA, patient was at the sidewalk when a tire of a 10 wheeler truck dislodged and struck directly onto his face incurring contusion and hematoma on the right eye and abrasion on the right brow area. There was associated blurring of vision, dizziness and eye pain. There was no accompanying loss of consciousness and eye redness. Hence consult and subsequent admission. Past Medical History: (-) Asthma (-) allergies (+) Previous hospitalizations: 1996 due to BFC Family History: (+) asthma-maternal (-) DM (-)HPN Previous Eye History: No previous eye infection or operation Personal / Social History: nd 2 year HS student Review of Systems: Skin: (-) rash, (-) itching EENT: no tinnitus, no Nasoaural discharge, no dysphagia, no sore throat Respi: no DOB, no cough, no colds, no hemoptysis Cardiovascular: no chest pain, no palpitations, no PND, no easy fatigability GIT: no nausea/ vomiting, no abdominal pain, no hematochezia, no melena, no change in bowel habit GUT: no dysuria, no oliguria, no nocturia, no hematuria Endo: No 3p’s, no heat and cold intolerance Hema: No easy bruising, no pallor Neuro: No LOC, no convulsion, no seizure

Physical Examination: Gen: Drowsy, NICRD VS: BP: 120/80 HR: 85 RR: 26 Temp: 39.5 Skin: good skin turgor, no rashes 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: flat, non distended, NABS, soft, nontender Extremities: grossly normal, full and equal pulses, no edema, no cyanosis Neuro exam:

Neurologic Exam: Cerebrum: oriented to 3 spheres CN I: can smell coffee CN II: right dilated to 5mm, left reactive to right 2-3mm CN III, IV, VI: EOM intact CN V: (+) bicorneal reflex CN VII: no facial asymmetry CN VIII: can hear sounds CN IX, X: gag reflex intact CN XI: can shrug shoulders CN XII: uvula midline Reflexes: No pathologic reflexes DTR: ++ | ++ ++ | ++


Visual Acuity: OD: OS:

sc NLP 20/25



External Eye Exam:
Dilated 5mm, sluggishly reactive to light (+) abrasion PERTL 2-3mm

Pink palpebral conjunctiva

+ contusion hematoma

Anicteric sclerae

Extraocular muscles:

Fundoscopy: OD: (+) ROR, CM, DDB, CDR 0.3, AVR 2:3, (-)H/E OS: (+) ROR, CM, DDB, CDR 0.3, AVR 2:3, (-)HIE

Slit lamp

Assessment: Contusion Hematoma (Periorbital Area) OD Abrasion, Lateral Canthal Area OD Traumatic Mydriasis OD Absolute Eye OD Plan: For admission

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