OSPITAL NG MAYNILA MEDICAL CENTERc` Department of Ophthalmology Name: Raquino, Olga Age/Sex: 62/F Address: Sampaloc, Manila Date of Admission: September 18, 2007; 10:30 am Admitting Diagnosis: Pseudophakia, OD; CSM OS Final Diagnosis: Pseudophakia, OU S/P Phacoemulsification with PCIOL, OS (LA) Physicians-in-charge: Drs. Reyes/Mateo/Corpuz Clerk-in-charge: Patayan/Raagas/Reloj Patient’s Discharge Summary This is a case of a 62-year-old female from Sta. Ana, Manila who came in due to progression of blurring of vision, OD. History of Present Illness: 3 years PTC, patient noticed blurring of vision described as cloudy, OS. Few months PTC, patient experiences itchiness, redness with discharge, without pain. Progression of signs and symptoms prompted consult. Past Medical History: (-) DM, HPN, asthma, allergies, TB Family History: (-) DM, HPN, asthma, allergies, TB Previous Eye History: none Personal and Social History: not a cigarette smoker and not an alcoholic beverage drinker. Review of Systems: Constitutional: No weight loss or gain, 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 Visual Acuity OD OS Refraction OD OS External Eye Exam 2-3 mm PERTL PPC SC 120/125 -2 CF 3 ft. Objective Rx N/A N/A PH 20/80 NIPH Subjective Rx Previous RX CC SC J CC Hospital No: 1647524 Date of Discharge: September 20, 2007
anicteric sclerae EOM
Slit Lamp Clear (-) uptake HHhhhH Clear (-) uptake
Fundoscopy OD: (+) ROR, other structures not seen OS: (+) ROR, other structures not seen Assessment: Plan: CSM OS
Course in the wards: Patient was admitted to room 215 Pay Philhealth under the service of Drs. Reyes/Mateo/Corpuz. Vital signs were monitored every 4 hours. Consent for admission was secured. She was on regular diet. Patient was prescribed with Levofloxacin E/S 1 gtt to OU q6. She was scheduled for Phacoemulsification with PCIOL OS (LA). 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 6:00am, and Acetazolamide 250mg tab, 2 tabs 2 hours prior to operation. 1st hospital day, patient was wheeled to the operating room with stable vital signs. He tolerated the operation well. After the operation, oxygen inhalation was discontinued. He was brought back to the ward and was put on previously ordered diet. 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: Cefalexin 500mg/cap 1 cap TID for 7 days, Mefenamic acid 500mg/cap 1 cap q6 as needed for pain on full stomach, Moxiclex E/S 1 gtt to OS and Gatifloxacin E/S 1 gtt to OS q1 for the 1st 24hour then q4 thereafter. Patient was seen by Dr. Reyes and was advised to follow-up at Ophthalmology OPD on September 25, 2007, Tuesday at 8:00am.