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OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF OPHTHALMOLOGY Patient’s Name: MALATE, Victorina Address: 991 A. Dagupan, Tondo, Manila Age/Sex: 69 year old/ Female Date of Admission: July 20, 2008 Admitting Diagnosis: Nasolacrimal Duct Obstruction (OD), CSI (OU) Physician–in-charge: Dr. Reyes/ Sumajit/Corpuz/Tormon Clerks-in-charge: Fabian/Ilarde/Inlges/Item/Junsay Hospital No: No.1488279 Room: 221 CLINICAL ABSTRACT This is a case of a 69 y/o female diagnosed with HPN stage 1 (non-compliant to medications), who came in due to excessive lacrimation of the right eye. HPI: 6 mos PTC, patient noted excessive lacrimation of the right eye, associated with eye itchiness, foreign body sensation, and blurring of vision that is transient. Persistence of symptoms prompted consult at OMMCOphthalmology. Past Medical History: S/P Tonsillectomy 1954 S/P TAHBSO 1984 No known allergies Family History: (+) DM- mother (-) HPN Previous Eye History: (+) reading glasses, 2 years but discontinue since 1 yr PTC Personal / Social History: Unemployed, non-smoker, non-alcoholic beverage drinker Physical Examination: Gen: Awake, alert, ambulatory NICRD VS: BP: 140/70 HR: 64 RR: 20 Temp: 36.9 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 20/60 – 1 20/50 - 1 ph 20/40 - 2 20/50 cc External Eye Exam: PERTL 2-3mm pink palpebral conjunctiva PERTL 2-3mm Pink palpebral conjunctiva Anicteric sclerae Anicteric sclerae (+) opacity Extraocular muscles: Fundoscopy: OD: (+) ROR, hazy media OS: (+) ROR, hazy media Slit lamp Assessment: NASO-LACRIMAL DUCT OBSTRUCTION (OD) CSI, OU Plan: For admission Patient may be admitted to room 221, Charity EYE ward under the service of Drs. Reyes/ Sumajit/ Corpuz/ Tormon. Patient may have low salt, low fat diet. Consent for admission was secured. Vital signs and Input & Output was monitored and recorded. Medications were: 1. Enalapril 10mg/tab, 1 tab OD before breakfast 2. Sulfacetamide Eye solution. 1 drop to both eyes QID 3. HCTZ 12.5mg OD before dinner Initial VA (OD 20/100—20/70-1, OS 20/40-2—20/40), AT (OD 14, OS 13) and LA (OD: obstructed, OS Patent) c/o RIC. 6 and 24-hour history c/o CIC. Patient was for OR booking and Anesthesia Department booking. IM RIC was informed for this admission.
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