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OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF OPHTHALMOLOGY Patient’s Name: RAMIREZ, Solidad L. Address: 2318 Tenorio st. SAB, Manila Age/Sex: 74 year old/ Female Date of Admission: July 24, 2008 Admitting Diagnosis: CSM Physician–in-charge: Dr. Reyes/ Sumajit/Gapay Clerks-in-charge: Fabian/Ilarde/Inlges/Item/Junsay Hospital No: No.1314254 Room: 219 PATIENT DISCHARGE SUMMARY This is a case of a 74 y/o female who came in due to blurring of vision of the right eye. HPI: 2 years PTC, patient was diagnosed with cataract, OU, S/P ECCE OD, 2006 OMMC. Due to persistent BOV, patient was scheduled for ECCE of OS hence consult then subsequently admitted. Past Medical History: (+) HPN for 5 years; on Metoprolol 50mg bid (-) DM (-) Asthma (-) allergies (-) Kidney disease (+) PTB about 10 years ago, S/P 6 months treatment Family History: Denies heredofamilial diseases Personal / Social History: Unemployed, non-smoker, non-alcoholic beverage drinker Physical Examination: Gen: Awake, alert, NICRD VS: BP: 220/100 HR: 80 RR: 22 Temp: 36.5 Skin: good skin turgor, no pallor, no cyanosis HEENT: anicteric sclera, PPC, no alar flaring, no neck vein distention, (+) anterior neck mass- moves with deglutition approx 2 x 2.5cm, non-tender located just above the sterna notch, no lymphadenopathy C/L: Symmetric chest expansion, no retractions, clear breath sounds th Heart: Adynamic precordium, PMI at 6 ICS AAL, 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 CF at 1 ft CF at 6 ft ph NIPH 20/200 - 2 cc External Eye Exam: PERTL 2-3mm pink palpebral conjunctiva PERTL 2-3mm Pink palpebral conjunctiva Anicteric sclerae Anicteric sclerae Extraocular muscles: Fundoscopy: OD: (-) ROR, inner structures can not be assessed OS: (-) ROR, inner structures can not be assessed Slit lamp Assessment: CSM, OD Plan: For admission Patient may be admitted to room 217, Charity 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. Losartan 50 + HCTZ 12.5 tab OD 2. Captopril 25mg/tab; 1 tab for BP >160/100 3. Metoprolol 5omg ½ tab BID Prepare 6 hour history, 24 hour history c/o CIC Initial VA, AT and NLDI c/o RIC. Pre-operative Orders: Please schedule patient for ECCE w/ PCIOL, OS under LA under the service of Drs. Reyes/Daffon/Samaniego/Ibasco 1000hrs. Please secure consent for surgery NPO post midnight 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. On the first hospital day, patient’s VA was CF @ 2ft (OD) and 20/200-----20/70(OS), AT 14 (OD), 13 (OS). Patient was transferred in the OR. Patient received the following post-operative orders: - May discontinue O2 inhalation May go back to the ward May receive previously ordered diet st nd Monitor vital signs every 15 minutes for the 1 hour, every 30 minutes for the 2 hour and every hour thereafter until stable. Medications: o Amoxicillin 500mg/cap, 1 cap q8 x 7d o Mefenamic acid 500mg/cap; 1 cap q6 for prn pain o Moxifloxacin (Vigamox) E/S; 1 gtt Od q4 o 5% NaCl E/S; 1 gtt od q1 o Prednisolone Acetate (pred forte) E/S; 1 gtt OD Q1. On the second hospital day, patient’s VA was 3/200 NIPH (OD) and 20/100+1--- 20/100 + 2. Patient was MGH once seen by Dr. Daffon. PDS c/o CIC; OR tech c/o IIC. Home Medications: 1. Amoxicillin 500 mg/ cap; 1 capsule 3x a day for 1 week 2. Mefenamic acid 500mg/cap; 1 cap q6 for pain on a full stomach 3. Moxifloxacin (vigamox) Eyedrops; 1 gtt to OS q 4 4. 5% NaCl eye drops; 1 gtt to OS q1 5. Prednisolone acetate eye drops; 1 gtt to OS q1 ff-up July 31, 2008 at the OPD.
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