Overview
Afrina Huda binti Ismail No known allergyNEWS2 0 · Routine · Continue routine observations every 12 hoursVIP
70y · Female · MRN MV-729657- Visit
- Day case · Daycare 021 · Day 1
- Clinician
- Dr. Michael S. H. Law
- Patient
- 1 of 1
Resident
- IC
- 560727-06-3726
- DOB
- 27/07/1956 · 70Y 2M 8D
Vitals
- BCVA
- OD—
- OS—
- IOP
- —not taken
- —not taken
- BP124/71
- Fall risk
- 05/10 High
- Pain
- 0/10 NRS · 05/10
- Payor
- ETIQA INSURANCE & TAKAFUL - INDIVIDUAL
- GL
- RM 5,900 Issued
- Precaution
- None
- Allergies
- NKA
- Isolation
- None · no biohazard
- Diet / NBM
- Blood
- B Rh+
- Ht / Wt
- 163cm · 66.2kg
- BMI
- 24.9 · BSA 1.73
- NOK
- Norazlan bin Rahman · Spouse
Diagnosis
5| H25.1 | Age-related nuclear cataract Primary | |
| E78.0 | Hypercholesterolaemia | |
| I10 | Hypertension | |
| E11.9 | Type 2 Diabetes Mellitus | |
| H36.0 | Diabetic retinopathy, R1 M0 OU |
Patient Visit
| Last Admission | 05/10Day case · Daycare |
| Last Visit | 03/10 · Follow UpCataract & Refractive · Dr. Michael |
| Next Appointment | 06/10 · Post-op D1Dr. Michael · Cataract & Refractive |
| This Visit | 05/10 · OP InpatientCataract & Refractive · Dr. Michael · ETIQA INSURANCE & TAKAFUL - INDIVIDUAL |
Medical / Surgical History
1| Surg | Hysterectomy Laparoscopic | 26/10/10 |
Family / Social History
Nothing recorded. Add family or social history with +.
Medication History
| Prednisolone Acetate 1% 5 ml Eye drops1 drop QID OS x 4/52 taper · Eye · day 1/28 | ||
| Moxifloxacin 0.5% 5 ml Eye drops1 drop QID OS x 1/52 · Eye · day 1/7 | ||
| Paracetamol 500 mg1000 mg prn · PO · day 1/3 | ||
| Omeprazole 20 mg20 mg OD · PO · day 2/30 |
Internal Referral
No internal referral. Refer with +.
Service Charges
6 RM 324.48| Consultation — Specialist | 200.00 | |
| HbA1c | 65.00 |
OT Booking
1| 05/10 | OSCataract Extraction with IOL PhacoemulsificationDr. Michael (Primary) | Recovery |
Checkpoint History
5| 08:21 | Lab / Radiology | Arrived |
Eye Results
7| 05/10 | 03/10 | 13/08 | ||
|---|---|---|---|---|
| BCVA | -- | OD 6/7.5OS 6/60 | OD 6/7.5OS 6/36 | |
| IOP | -- | OD 11OS 12 | OD 10OS 12 | |
| CMT | -- | -- | -- |
Laboratory
2| Fasting Blood Sugar05/10 | 10.4 H | |
| HbA1c05/10 | 7.1 H |
Diagnostic
5| Fundus photograph25/09 · OD R1 M0 · OS R1 M0 | |
| Specular microscopy25/09 · OD 2480 · OS 2610 cells/mm² |