Chart

My day Mohd Ridzuan bin IsmailMV-703021
51y · Male · MRN MV-703021 · IC 750101-12-4499

Clinical Summary

  • Day case · Daycare Dr. Chan Jan Bond
    05/10/2026
Clinical note
Pseudophakia OS (Z96.1); age-related nuclear cataract (H25.1) operated — phacoemulsification with IOL OS done; BCVA OS 6/36, unchanged; IOP 17 mmHg.
Diagnosis
H25.1 Age-related nuclear cataract (OS)
Care plan
Home today on Moxifloxacin 0.5% 1 drop QID OS x 1/52, Prednisolone Acetate 1% 1 drop QID OS x 4/52 taper. Eye shield at night, no rubbing or bending. Review post-op D1 on 06/10/2026. Repeat HbA1c, Fasting Blood Sugar before the next visit.
Follow-up
Post-op D1 · 06/10

Test Reports

  • HbA1c Range 4 – 5.6
    05/10/2026
  • Fasting Blood Sugar Range 3.9 – 5.5
    05/10/2026
  • OCT macula OD 297 · OS 292 µm CMT
    20/09/2026
  • Biometry OD 22.25 · OS 22.55 mm ALAcrySof IQ Toric SN6AT5 22 D
    20/09/2026
  • Corneal topography OD 46 · OS 46 D Kmax
    20/09/2026
  • Specular microscopy OD 2920 · OS 2830 cells/mm²
    20/09/2026
  • Fundus photograph OD R1 M0 · OS R1 M0
    20/09/2026
  • B-scan ultrasound Dense nuclear cataract, no fundal view
    20/09/2026

Current medicines

7
  • Moxifloxacin 0.5% 5ml Eye drops 1 drop QID OS x 1/52 · Eye
  • Prednisolone Acetate 1% 5ml Eye drops 1 drop QID OS x 4/52 taper · Eye
  • Paracetamol 500mg (Panadol) 1000 mg prn
  • Metformin 500mg (Glucophage) 500 mg bd
  • Bisoprolol 2.5mg (Concor) 2.5 mg od
  • Atorvastatin 20mg (Lipitor) 20 mg on
  • Amlodipine 5mg (Norvasc) 5 mg od

Visit

6 Cataract & Refractive
  • Upcoming3
  • Post-op D1 Dr. Chan Jan Bond
    06/10/2026
  • Post-op W1 Dr. Chan Jan Bond
    12/10/2026
  • Post-op M1 Dr. Chan Jan Bond
    04/11/2026
  • Current stay
  • Admitted Daycare · 002
    05/10/2026
  • Past visits
  • Follow Up · Cataract & Refractive Dr. Chan Jan Bond
    21/08/2026
  • Follow Up · Cataract & Refractive Dr. Chan Jan Bond
    12/07/2026
  • Follow Up · Cataract & Refractive Dr. Chan Jan Bond
    30/05/2026
  • New Case · Cataract & Refractive Dr. Chan Jan Bond
    20/04/2026
  • Follow Up · Cataract & Refractive Dr. Chan Jan Bond
    07/03/2026

Diagnoses

5
  • H25.1 · Age-related nuclear cataract (OS) Since 07/03/2026
  • E78.0 · Hypercholesterolaemia Since 12/08/2021 · comorbidity
  • I10 · Hypertension Since 18/01/2021 · comorbidity
  • E11.9 · Type 2 Diabetes Mellitus Since 26/09/2018 · comorbidity
  • H36.0 · Diabetic retinopathy, R1 M0 (OU) Since 07/12/2021 · comorbidity

Procedure

8
  • Refraction
    05/10/2026
  • Cataract Extraction with IOL Phacoemulsification · OS
    05/10/2026
  • OCT macula
    20/09/2026
  • Biometry
    20/09/2026
  • Corneal topography
    20/09/2026
  • Specular microscopy
    20/09/2026
  • Fundus photograph
    20/09/2026
  • B-scan ultrasound
    20/09/2026

Vital signs

6
Temp 36.6 °CPulse 68 bpmBP 129/66 mmHgSpO₂ 99 %RR 17 /minWt 67.3 kg

Allergy

0

No known allergy.