120 McArthur High-way, Valenzuela City

Department of Ophthalmology
Clinical History
Name: Tuason, Dionisio De Leon
Age/Sex: 83 years old/ Male
Address: B7 L5A Buenavista Subd Bagong Silang Balanga City Bataan
Date of Admission: February 2, 2017
Date of Discharge: February 4, 2017
Attending Physician: Dr. Marie Joan Veneracon Loy
Admitting Diagnosis: Retinal Detatchment, Right eye
Final Diagnosis: s/p Pars Plana Vitrectomy, Scleral Buckling, membrane peeling, air fluid exchange, endolaser, silicone oil
injection, Right eye
Patient/ Room: 178134/702

Tuason, Dionisio De Leon, 83 year old, male, married, Roman catholic, Filipino, Born on December 27, 1933, currently
residing at B7 L5A Buenavista Subd Bagong Silang Balanga City Bataan, admitted for the second time at our institution on February
2, 2017.

Chief complaint: Blurring of vision

History of Present Illness:

2 months prior to consult, while patient was reading, he was suddenly accidentally hit by his grandson on the right eye.
Patient complained of pain on the right eye. There were no associated blurring of vision, nausea, vomiting, headache, tearing and
hyperemia. No medications were taken. No consult was done.
2 weeks prior to consult, still with the above signs and symptom but now with blurring of vision on the right eye. There were
no associated blurring of vision, nausea, vomiting, headache, tearing and hyperemia. No medications were taken. Consult was done at
St. Luke’s Medical Center where he was advised for surgery hence he scheduled at our institution for the contemplated procedure.

Past Ocular History:

(+) Unknown ocular surgery last October 2016 at FUMC

Past Medical History

(+) COPD diagnosed last Decmber 2016

(-) HPN (-) DM
(-) Heart Disease (-) Lung Disease
(-) Liver Disease (-) Thyroid Disease
(-) Kidney Disease (-) Allergy

Family History
(-) HPN (-) DM
(-) Heart Disease (-) Lung Disease
(-) Liver Disease (-) Thyroid Disease
(-) Kidney Disease (-) Allergy

Personal and Social History

(+) Previous Occasional alcoholic drinker
(+) Previous Smoker consuming 1 pack per day for 50 years

Review of Systems:
General: (-) weight loss, (-) chills, (-) fatigue, (-) loss of appetite
Skin: (-) color change, (-) sores, (-) rash, (-) scaling, (-) bleeding, (-) itching
HEENT: (-) headache, (-) neck stiffness, (-) colds, (-) nasal discharge, (-) bleeding gums, (-) oral ulcer,
(-) hoarseness

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Respiratory: (-) cough, (-) dyspnea, (-) shortness of breath, (-) pleuritic chest pain
CVS: (-) chest pain, (-) palpitation, (-) orthopnea, (-) paroxysmal nocturnal dyspnea, (-) easy fatigability
GIT: (-) dysphagia, (-) hematemesis, (-) nausea, (-) vomiting, (-) diarrhea, (-) constipation, (-) melena
GUT: (-) dysuria, (-) hematuria, (-) retention, (-) incontinence, (-) frequency, (-) urgency
Musculoskeletal: (-) gout, (-) knee pain (-) myalgia, (-) arthralgia, (-) backache
Endocrine: (-) polyuria, (-) polydipsia, (-) polyphagia, (-) heat/cold intolerance
Hematologic: (-) pallor, (-) easy bruising
Neuropsych: (-) seizure, (-) dizziness, (-) tremors, (-) depression, (-) hallucination

Physical Examination
General Survey: Conscious, coherent, ambulatory, not in cardiorespiratory distress
Vital Signs: BP: 110/70 mmHg PR: 98 bpm RR: 20 cpm T: 36.4 °C
Skin: Skin is brown, warm to touch, moist, with good skin turgor, no lesions
HEENT: Anicteric sclera, pinkish palpebral conjunctivae, no nasaoaural discharge, no tonsillopharyngeal congestion,
no cervical lymphadenopathy
Chest & Lungs: Symmetrical chest expansion, no lagging, no retractions, clear and equal breath sounds
Heart: Adynamic precordium, tachycardic at 128bpm with regular rhythm, no murmur
Abdomen: Globular, with normoactive bowel sounds, soft, non-tender
Extremities: Grossly normal extremities, no edema, no cyanosis, no pallor, with full equal pulses on radial and brachial
arteries
Neurologic Exam:
Cerebrum: alert, coherent, oriented to time, place, person; GCS 15 (E4V5M6)
Cerebellum: able to do alternating supination-pronation test
Cranial Nerves:
I: Not Asscessed
II, III: Pupils round; Reactive to light (direct & consensual), OU
III, IV, VI: Intact EOM movement
V: Intact muscles of mastication
VII: No facial asymmetry
VIII: Intact
IX, X: Uvula at the midline, intact gag reflex
XI: Able to shrug shoulder with and without resistance
XII: Tongue is in the midline upon protrusion

Motor Sensory DTR

5/5 5/5 100% 100%

++ ++
++ ++

++ ++

5/5 5/5 100% 100%

EYE EXAMINATION

I. Visual Acuity

Distance Visual Acuity Near Visual Acuity

Uncorrected Uncorrected

II. Ocular Motility

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 OD OS

III. Pupillary Exam

OD OS
Pupil Size 3mm 3mm
Consensual Light + +
Reflex
Direct Light Reflex + +
RAPD - -

IV. External Examination

(-) Hyperemic (-) Hyperemic

(-) Discharge (-) Discharge
(-) Hemorrhage (-) Hemorrhage
(-) Itching (-) Itching

V. Visual Field Exam:

+ + + +

+ + + +

OS OD

Admitting diagnosis: Retinal Detatchment, Right eye

Plan: For Admission

For Pars Plana Vitrectomy, Scleral Buckling, endolaser, silicone oil injection, Right eye under General
Anesthesia

_________________
Dr. Marck Reyes Adajar, Gisella Marie L./ Agreda, Angelini S.
Resident-in-charge Junior Intern

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