Ospital ng Maynila Medical Center DEPARTMENT OF OPHTHALMOLOGY Quirino Avenue corner Roxas Boulevard Malate, Manila
Name: PLANILLA, Ronaldo Hospital No. 1857167 Age/Sex: 35/M Room No: 221 Address: 1141 Honoria Subdivision, Dela Paz, Binan, Laguna Date Admitted: July 7, 2008 Admitting Diagnosis: Fungal Keratitis Physicians-in-charge: Dr Reyes/ Carino/ Sumajit/ Corpuz/ Gapay/ Ibasco CIC: Mercado, Molina, Moreno, Montesa, Gaba
CLINICAL ABSTRACT This is a case of a 35 year old male who was brought in due to redness of left eye. .
HISTORY OF PRESENT ILLNESS: 14 days PTA, the patient was at home when liquid from a spoiled fruit accidentally splashed into his left eye. The patient immediately flushed out the liquid with running water and self-medicated with Eye-mo ® solution, which afforded temporary relief. (-) eye redness, (-) Blurring of vision. 12 days PTA, the patient noted erythema on his left eye. (+) foreign body sensation, (+) excessive lacrimation, (-) exudate formation, (-)fever, (-) blurring of vision, (-) dizziness. Patient consulted at a private ophthalmologist and was prescribed with Tobramycin 0.3%+ Dexamethasone 0.1% 1 gtt to OS QID for 7 days and Dexpathenol 1 gtt to OS BID for 7 days, with temporary relief of symptoms. 4 days PTA, the patient again consulted his ophthalmologist because the previous symptoms persisted and a whitish opacity was noted on his left eye. (+) blurring of vision, (+) headache. Patient was advised to stop instilling any eye medications in preparation for corneal scraping for samples. 3 days PTA, patient’s left eye was noted to be more erythematous and the whitish opacity became larger. His left eye was scraped for samples which were subsequently sent to PGH. Patient was then prescribed with Moxifloxacin 0.5% 1 gtt q15 for 3 days, tobramycin 1 gtt to OS q15 for 3 days, atropine 1% 1 gtt to OS 3x daily for 3 days and acetazolamide tablet 500mg, 1 tab BID for 3 days. 1 day prior to admission, the previous symptoms persisted, hence admission to OMMC. PAST MEDICAL HISTORY: (-) HPN (-) DM (-) asthma (-) allergy (-) PTB (+) previous ER consults at Calamba Doctors Hospital in 2004-2005 due to GERD, resolved Family History (+) HPN (maternal side), (+) DM, (-) CVD, (-) asthma, (-) kidney disease, (-) thyroid problems, (-) cancer Previous Eye History none Review of Systems General: (-) loss of appetite, (-) weight loss Skin: (-) rashes, (-) itchiness HEENT: (-) tinnitus, (-) vertigo, (-) dysphagia Respiratory: (-) DOB, (-) cough, (-) hemoptysis Cardiac: (-) chest pain, (-) palpitations, (-) easy fatigability Gastrointestinal: (-) vomiting, (-) abdominal pain, (-) change in bowel habit Genitourinary: (-) nocturia, (-) dysuria, (-) hematuria Hematology: (-) easy bruising or bleeding, (-) pallor Endocrinology: (-) polyuria, (-) polyphagia, (-) polydipsia Musculoskeletal: (-) joint pains Neuro: (-) loss of consciousness, (-) convulsion, (-) seizures PHYSICAL EXAMINATION: General: awake, alert, not in cardiorespiratory distress Vital Signs: HR = 78 bpm RR = 19 cpm Temp = 36.8 degrees Celsius Weight: 83 kg Skin: good skin turgor, (-) hematoma,
Head: (-) deformities Face: (-) asymmetry ENT: (+) nasal discharge Chest: symmetric chest expansion, (-) retractions, (+) NRRR, clear breath sounds Abdomen: flat, soft, no masses, NABS, (-) abdominal distention Extremities: grossly normal, (-) cyanosis, (-) edema, (+) full and equal pulses. VA OD: 20/20 OS: 10/200 NIPH External Eye Exam: Whitish opacity PERTL 2-3mm (+) exudates
pink palpebral conjuctiva
Anicteric sclera erythematous Extraocular muscles: Fixed dilated pupils 6 mm
erythematous palpebral conjunctiva
Fundoscopy: OD: (+) ROR, CM, DDB, CDR 0.3, AVR 2:3, (-) H/E OS: (+) ROR, CM, DDB, CDR 0.3, AVR 2:3, (-) H/E (-) opacity Slit lamp cortical cortical PSC PSC 1x 6x 1x (-) uptake (+) ulcer 1x 6x 1x (-) opacity
Hypopyon 0.5 mm
ASSESSMENT: Fungal keratitis, OS PLAN: For admission Course in the Wards: Patient was admitted at room 221 under the service of Drs Reyes/ Carino/ Sumajit/ Corpuz/ Gapay/ Ibasco. His initial VA was OD: 20/20, OS 10/200 NIPH. AT OS: (-). Patient was monitored q4 and allowed DAT. Labs done were GSCS/ KOH of corneal scraping. Medications prescribed were as follows: Amphotericin B E/S q15 to OS, Atropine E/S TID to OS, Moxifloxacin q3 to OS, Tobramycin q3 to OS and Paracetamol + Tramadol 37.5 mg/ 325 mg tab BID PO. Daily keratectomy was advised c/o External Diseases resident/ rotator.
On the second hospital day, VA was OD 20/20, OS CF at 1 foot20/200. Eye shield to OS was placed at all times except during instilling medications. Daily keratectomy was done c/o of ED-RIC. Previous medications were continued. Dr Carino was updated regarding the patient’s status.
2.4 x 4.3mm
On the third hospital day, VA was OD 20/20, OS 15/200 20/200. +2 - +3 CF Eye shield was placed at all times except when instilling medications. Daily keratectomy was done c/o ED-RIC. Medications given were as follows: Amphotericin B E/S q15 to OS, Atropine E/S TID to OS, Moxifloxacin q3 to OS, Tobramycin q3 to OS and Paracetamol + Tramadol 37.5 mg/ 325 mg tab BID PO. Acetazolamide 250mg/tab, 1 tab BID, to consume amphotericin B E/S then may shift to Diflucon E/S 1 gtt to OS q15 c/o Dr Carino. 1x
2.4 x 4mm