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OSPITAL NG MAYNILA MEDICAL CENTER Department of Ophthalmology Name: DELOS SANTOS, CORAZON Age/Sex: 63/F Address: 3420 Del Rosario, Tondo, Manila Assessment: CSI, OU (OD>OS) Physician-in-charge: Brucelas Clerk-in-charge: Patayan/ Raagas/ Reloj Clinical Abstract This is a case of a 63 year-old female from Del Rosario, Tondo, Manila who came in due to blurring of vision on both eyes. History of Present Illness: 3 years PTC, patient felt foreign body sensation, OU with redness and occasional mucoid discharge. Patient then consulted at the ophtha-OPD, OMMC where she was prescribed with Tobradex E/S 1 gtt q6 to both eyes. This afforded relief. 1 year PTC, patient noticed that she has blurring of vision, OU. Patient consulted at Ophtha-OPD, OMMC where she was advised to undergo operation. However, due to financial constraint, patient was unable to comply. Progression of blurring of vision prompted the patient to consult again at this institution. Past Medical History: (+) HPN (-) DM, BA Family History: no heredofamilial diseases Previous Eye History: (+) Blepharoconjunctivitis, OU; CSI, OU; Rx – Tobradex E/S 1 gtt q6h OU Personal and Social History: (+) occasional alcoholic beveragae drinker, (+) smoker 2.5 pack years, (+) coffee drinker 1-2 cups/day Review of Systems: Constitutional: No weight loss or gain, no irritability, no chills, no fever, no anorexia Skin: No unusual pigmentation, no itchiness HEENT: (+) colds, no ear discharge, no hoarseness Respiratory: No increased respiratory effort, no cough, no hemoptysis Cardiovascular: No cyanosis, no complaint of chest pain, no palpitations GIT: No diarrhea, no melena, no hematochezia GUT: No hematuria, no dysuria Hematology: No poor wound healing, no easy bruisability Neurology: No seizure, no tremors, no loss of consciousness Visual Acuity OD OS Refraction OD OS External Eye Exam 2-3 mm PERTL SC 20/200 – 2 20/125 Objective Rx PH 20/125 -1 20/50 -2 Subjective Rx CC SC 20/200 20/70 -1 Previous RX J CC Hospital No: 1460730 PPC PPC Anicteric sclerae EOM Slit Lamp Clear (-) uptake Clear (-) uptake CNH (-) C/F 1x 6x 1x 1x 6x 1x Fundoscopy OD: (+)ROR, hazy media, DDB, AVR 2:3, CDR 0.3, (-) H/E, (+) peripapillary atrophy OS: (+) ROR, hazy media, DDB, AVR 2:3, CDR 0.3, (-) H/E, (+) peripapillary atrophy Assessment: Plan: CSI, OU (OD>OS) ; Blepharitis, OU For work-up TCB with results Warm compress for 15 minutes Lid scrub TID OU Tobradex E/O apply TID OU Course in the wards: Patient was admitted under the service of Drs. Reyes/Mateo/Corpuz. Vital signs were monitored every 4 hours. Consent for admission was secured. He was on diet as tolerated. Laboratory diagnostics requested were: CBC with CT/BT, FBS, UA, ECG, and CXR-PA. He was scheduled for Phacoemulsification with PCIOL, OS under the service of Drs. Reyes/Sumajit/Corpuz at 1000 hours. Consent for operation was secured. He was on NPO at midnight. Full facial, oral, body hygiene prior to operation was requested. Medications given were: Tropicamide E/S and Diclofenac E/S, 1 gtt to OS q10minutes to start at 5:00am, and Acetazolamide 250mg tab, 2 tabs 2 hours prior to operation.
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