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OSPITAL NG MAYNILA MEDICAL CENTER Department of Ophthalmology Name: CLEMENTE, MARINA Age/Sex: 81/F Address: 9513 Kasunduan St., Brgy. Commonwealth, Quezon City Date of Admission: September 13, 2007; 10:30am Admitting Diagnosis: CSM OD; CSI OS Final Diagnosis: Pseudophakia, OD; CSI, OS Physicians-in-charge: Drs. Reyes/Mateo/Corpuz Clerk-in-charge: Patayan/ Raagas/ Reloj Patient’s Discharge Summary This is a case of an 81-year-old female from Brgy. Commonwealth, Quezon City who came in due to progression of blurring of vision. History of Present Illness: 1 year prior to consult, patient has been experiencing blurring of vision described as haziness or clouding associated with excessive tearing, itchiness of the right and dizziness (non-rotatory). No headache, no nausea, no vomiting. No medications taken. Progression of blurring of vision prompted consultation thus the subsequent admission. Past Medical History: (+) PTB; 1999, underwent unrecalled medications (-) HPN, DM, BA Family History: no heredofamilial history Previous Eye History: None Personal and Social History: nonsmoker, non-alcoholic beverage drinker, coffee drinker 2x/day Review of Systems: Constitutional: No weight loss, no irritability, no chills, no fever Skin: No unusual pigmentation, no itchiness HEENT: No ear discharge, no hoarseness Respiratory: No increased respiratory effort, no cough, no hemoptysis Cardiovascular: No easy fatigability, 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 Physical Examination: VS: HR: 78 bpm RR: 19 Temp: 36.5 C BP 140/80 General: Conscious, coherent, not in cardiorespiratory distress HEENT: anicteric sclerae, pink palpebral conjunctivae, no tonsillopharyngeal congestion, no cervical lymphadenopathy Visual Acuity OD OS Refraction OD OS External Eye Exam 2-3 mm PERTL PPC SC OF in 1 ft 20/63 -2 Objective Rx N/A N/A PH OF in 1 ft 20/63 Subjective Rx Previous RX CC SC J CC Hospital No: 1454995 Date of Discharge: September 14, 2007 PPC (+) toothpaste sign whitish lining anicteric sclerae EOM Slit Lamp Clear (-) uptake HHhhhH Clear (-) uptake III CN II 1x Applanation Tonometry: OD: 15 OS: 16 6x 1x 1x 6x 1x Fundoscopy OD: (+) faint ROR, hazy media, (+) exudates OS: (+) ROR, CM, DDB, (+) exudates Chest and Lungs: Symmetric chest expansion, no retractions, clear breath sounds Heart: Adynamic precordium, normal rate, regular rhythm, no murmurs Abdomen: flat, normoactive bowel sounds, soft, nontender, no organomegaly Extremities: grossly normal, no edema, no cyanosis, full and equal pulses Assessment: Plan: CSM OD; CSI OS t/c DM vs. HPN retinopathy For admission 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. She was on diet was tolerated. She was given Levofloxacin (Oftaquix) E/S q1hour to OU TID. She was scheduled for ECCE with PCIOL, OD under local anesthesia under the service of Drs. Reyes/ Daffon/ Corpuz at 0700 hours. Consent for operation was secured. She 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. On the 1st hospital day, patient was wheeled in to the operating room with stable vital signs. She tolerated the operation well. After the operation, she was put on diet previously ordered. Vital signs were monitored every 15 mins for the first hour, then every 30 mins for the second hour, then q1 until stable. Medications given were: Amoxicillin 500mg/cap 1 cap TID for 7 days, Mefenamic acid 500mg/cap 1 cap q6 as needed for pain on full stomach, Prednisolone acetate E/S 1 gtt to OD q1, 5% NaCl E/S 1 gtt to OD q1 and Gatifloxacin E/S 1 gtt to OD q4. Patient was scheduled to come back at OPD on September 18, 2007.
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