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Case PresentationCase PresentationSABALBURO, MARIA KATHLEEN ROSE T. | MD080054

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Identifying DataIdentifying Data

GMP

73, Female

11/23/1938

Filipino Roman Catholic

Widow

Mageyegyeg, La Union, Pangasinan (Currently:Antipolo)

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Chief Complaint

Blurring of Vision

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History of Present Illness

4

6 mos

PTA

Gradual blurring of vision

ADMISSION

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Past Medical History

Arthritis since 2005

(-) Hypertension, (-) Diabetes Mellitus

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Family History

6

Maternal: Arthritis

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Personal-Social History

Retired

College graduate

Non-smoker, non-alcoholic beverage drinker

Denies use of illicit drugs

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Personal-Social History

Widow, lives alone

Dwelling: Lives in a one-storey house, 1 bedroom, 1

comfort room, owned, compound area with other

relatives homes

With 1 child with her own family that lives abroad

Financial: Pension, no support from child

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Review of Systems

General: No weight loss, fever, fatigue, weakness

Skin: No rashes, itchiness, hair and nail changes; No jaundice

Head and Neck - Eye: No redness, itchiness, pain, visual

dysfunction, Ear: No discharge, tinnitus, Nose: No epistaxis,discharge, Throat: No mouth sores or bleeding gums, Neck:

No stiffness, masses, lymphadenopathy

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Review of Systems

Pulmonary: No dyspnea, shortness of breath, cough, back

pain

Cardiovascular: No chest pain, orthopnea, palpitations,

syncope, varicosities or claudication Endocrine: No heat/cold intolerance, breast/voice changes

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Review of Systems

Gastrointestinal: No nausea, hematemesis, dysphagia

Genitourinary: No nocturia, urinary frequency, dysuria,

uretheral discharge

Musculoskeletal: No joint stiffness, pain, swelling, cramps,muscle pain, weakness, wasting

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Review of Systems

Hematologic: No abnormal bleeding, bruising, pallor,

adenopathies

Neurologic: No headache, seizures, sensory/motor

dysfunction, speech disturbances, mental status changes

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Physical Examination

Anthropometrics

Height: 1.7 m

Weight: 78 kg BMI: 27.0 kg/m2

Vital Signs

BP 159/70 mmHg

H

R 80 RR 19

Temp 36.6C

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Ophthalmic ExamOphthalmic ExamOD OS

VA HC

VA PH

20/60

20/30

20/70

20/30

LIDS (-) ptosis, lesions (-) ptosis, lesions

LASHES No matting, directed outward No matting, directed outward

CORNEA Clear Clear

CONJUNCTIVA Pink (palpebral) Pink (palpebral)

SCLERA Anicteric Anicteric

PUPILS Round, ERTL, 2-3 mm Round, ERTL, 2-3 mm

IRIS

EOM

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Ophthalmic ExamOphthalmic ExamOD OS

LENS (+) Opacity Clear

FUNDOSCOPY (+) ROR, Distinct disk borders,

CDR = 0.4, AVR = 2:3

(-) ROR

IOP 13 (applanation) 15.4 (applanation)EOMS Orthophoric, Full movement on

all cardinal fields

Orthophoric, Full movement on

all cardinal fields

Gonioscopy Grade 4 on all sides Grade 4 on sup, med, & lat

Inferior cant be assessed due to

(+) iridocorneal adhesion exactlyat 6 oclock area

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ODOD

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OSOS

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ODOD(Slit Lamp)(Slit Lamp)

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OSOS(Slit Lamp)(Slit Lamp)

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