Additional information of medical records received from health authority on 26mar2021, which states that on (b)(6) 2020, female patient put a contact lens into her left eye that had been soaked in hydrogen peroxide contact solution for cleaning.Patient had an instant burning feeling so she took the contact out, and flushed her eye.Patient also experienced eye crusted shut, itchy, worsen with constant drainage and pain.Consumer barely see, eye was very red and it hurts when tried to open completely/ squinting slightly, matting of eyelashes.Consumer said this might be due to something on hand after working with plants and rubbed eye hopping bacteria and requested for some antibiotics.On (b)(6) 2020 the patient contacted care chat regarding pink eye in left eye since removed contact lens.She was given some otc eye drops but pain from light excruciated.Patient had history of myocardial infraction (mi) and ovarian cancer.Ongoing medical events include hypothyroid, panic disorder without agoraphobia, depression, hot flashes, insomnia, s/p mitral valve replacement (mvr), anti-coagulation monitoring (inr range 2.5-3.5).Patient was using inr monitoring strips to check coagulation, central nervous stimulant 20 mg, steroid hormones 0.5mg, anticoagulants 5mg and 1mg, antidepressant 75mg twice daily, beta blockers 25mg (extended release), angiotensin converting enzyme inhibitors (ace) 2.5mg, anti-lipemic agents 54mg, hmg-coa reductase inhibitors (statins) 10 mg, thyroid hormones 0.125mg in empty stomach at least 30 minutes before food.All the medication was administered via oral route.The symptoms epithelial defect was resolved and no longer feels much pain.On (b)(6) 2020 diagnosis confirmed inferior hypopyon 1mm.As per on (b)(6) 2020, the patient was transferred to urgent care for the concern of left globe rupture with ongoing left eye problems such as increased pain (rated 7/10), inability to open left eye secondary to swelling.Patient also mentioned burning, throbbing, radiating down check, alleviated with percocet, frontal headache, chills, nausea with no vomiting.Diagnosis confirmed corneal ulcer: pan corneal infiltrate with minor thinning centrally with local erythema/ edema, possible cellulitis vs inflammatory reaction.Left eye examination revealed moderate erythema and swelling to the upper and lower eyelids, moderate amount of purulent as well as clear watery discharge, eyelids matted shut, significant chemosis, purulence under the eyelid, unclear whether large hypopyon versus purulence matted to the cornea, unable to clearly visualize the pupil.Patient had history of myocardial infraction (mi), mitral valve replacement (mvr), hypothyroidism, depression.Patient was currently using anticoagulants, antidepressant, thyroid hormones, angiotensin converting enzyme inhibitors (ace), beta blockers, hmg-coa reductase inhibitors (statins), all the medication was administered via oral route.On (b)(6) 2020 at 18:47 temperature c: 36.2 degree celsius (range: 36.6 -36.7), temperature source: temporal artery, heart rate: 74 bpm (range 70-75), respiratory rate: 16 br/min (range 16-16), sbp- noninvasive: 137 mmhg high (range 105-112), dbp- noninvasive: 72 mmhg (range 58-76), spo2: 100%, o2 delivery device: room air.At 21: 07 temperature c: 35.8 degree celsius, temperature source: temporal artery, heart rate: 86 bpm, respiratory rate: 16 br/min, sbp- noninvasive: 142 mmhg high, dbp- noninvasive: 74 mmhg, spo2: 100%, o2 delivery device: room air.At 22:00 temperature c: 36 degree celsius, temperature source: temporal artery, heart rate: 88 bpm, respiratory rate: 16 br/min, sbp- noninvasive: 144 mmhg high, dbp- noninvasive: 76 mmhg, spo2: 100%, o2 delivery device: room air.At 22:32 temperature c: 36.7 degree celsius, temperature source: oral, heart rate: 80 bpm, respiratory rate: 16 br/min, sbp- noninvasive: 148 mmhg high, dbp- noninvasive: 75 mmhg, bp-method: automatic, bp-extremity: left, arm, upper, vital sign reason: routine, spo2: 99%, o2 delivery device: room air.Examination revealed amylase (total): 27 units/l (range 27-106), lipase level: 23 units/l (range not less than 70), height for calculation: 157.4 cm, weight for calculation: 62.5 kg, body mass index: 25.2 kg/m2, rapid hsv pcr specimen desc/ varicella zoster pcr: swab in vital transport media, eye c and s w/gram: occasional pseudomonas aeruginosa, eye fungal w/direct exam: no fungus isolated in 4 weeks.Rapid hsv 1 pcr result, rapid hsv 1 ct value, rapid hsv 2 pcr results, rapid hsv 1 ct value, rapid hsv pcr interpretation, bacterial detection by pcr these all were in progress.Basic metabolic panel examination of sodium: 133 meq/l (range 153-145), potassium: 5.0 meq/l (range 3.6-5.2), chloride: 97.0 meq/l (range 99-108), carbon dioxide: 26 meq/l (range 22-32), anion gap: 10 (range 4-13), glucose: 102 mg/dl (range 65-140), bun: 24 mg/dl (range 6-24), creatine: 0.88 mg/dl (range 0.50-1.20), calcium: 9.3 mg/dl (range 8.6- 10.3), estimated gfr african american: above 60 (60 ¿ 100 ml/min), estimated gfr non- african american: above 60 (60 ¿ 100 ml/min), patient protime: 47.8 hh (range 11.0-15.0), intl.Normal ratio: 5.0 hh (range 0.8-1.2).Cbc, diff/ smear evaluation of wbc (white blood cells): 14.5 thou/ul (range 4.0-10.7), rbc (red blood cells): 4.01 mil/ul (range 3.6-5.0 10*6), hemoglobin: 11.9 g/dl (range 11.4-15.5), hematocrit: 37 % (range 34-46), mcv (mean corpuscular volume): 91 fl (range 80-98), mch (mean corpuscular hemoglobin): 30 pg (range 27.3-33.6), mchc (mean corpuscular hemoglobin concentration): 33 g/dl (range 32.2-36.5), platelet count: 376 thou/ul (range 150-400),rdw: 14.6 %(range 8.0-18.5), neutrophils absolute: 11.4 h (range 2.00-7.30 k/ul), lymphocytes absolute: 1.8 (range 1.00-3.40 k/ul), monocytes absolute: 1.8 (range 1.00-3.40 k/ul), eosinophils absolute: 0.3 (range 0.0-0.5 k/ul), basophils absolute: 0.1 (range 0.0-0.2 k/ul).On the same day pain has become unbearable in the left eye, prompting to seek care.On (b)(6) 2020 patient was noted to have been developing an infection (inferior hypopyon 1mm on (b)(6), left eye was swollen with clear and white discharge, eyelid was red, swollen and firm.The patient was started on quinolone antibiotics and aminoglycoside antibiotics q2 hours alternating to fluoroquinoline and tetracycline antibiotics and continued with eye drops (q1 antibiotic eye drop, pain relievers and opioid analgesics) and pain was managed.Covid-19 qualitative pcr indication/ nasal and oral surveillance swab showed no methicillin resistant staphylococcus aureus isolated, prothrombin time: 35.6s (range 10.7-15.6) and prothrombin inr: 3.5 (range 0.8- 1.3).Pain in left eye was ongoing.On (b)(6) 2020 reported sever pain in left eye and continues with peri-orbital edema and discoloration.Patient was increased with 4 mg opiate analgesics q4 hours (from 2mg), iv antibiotics and pain killer 2mg three times a day was given for pain.Prothrombin time: 33.5s (range 10.7-15.6) and prothrombin inr: 3.2 (range 0.8- 1.3).Diagnosed with chemical injury.Patient states eye pain is better controlled.On (b)(6) 2020 left eye had severe edema, sclera red and pupil milky white, went blind in left eye, severe burning pain, left eyelid was red, swollen and firm with draining clear to yellow fluid.Patient was given 4 mg opiate analgesics q4, pain relievers q6, started glycopeptide antibiotics, penicillin class of antibiotics, glucose tolerance test applied while patient awake, q1 for 3 hours while awake.Daily weight showed 57 kg, blood c& s culture: blood antecubital vein and no growth 5 days in both eye (ou).Basic metabolic panel examination of sodium: 133.0 meq/l (range 153-145), potassium: 3.9 meq/l (range 3.6-5.2), chloride: 96.0 meq/l (range 98-108), carbon dioxide: 30.0 meq/l (range 22-32), anion gap: 7.0 (range 4-12), glucose: 123.0 mg/dl (range 62-125), urea nitrogen: 20.0 mg/dl (range 8-21), creatine: 0.87 mg/dl (range 0.38-1.02), calcium: 9.7 mg/dl (range 8.9- 10.2), estimated gfr more than 60ml/min/1.73m2 (range more than 59).Cbc, diff/ smear evaluation of wbc (white blood cells): 14.39 thou/ul (range 4.30-10.00), rbc (red blood cells): 3.04 mil/ul (range 3.80-5.00), hemoglobin: 8.9 g/dl (range 11.5-15.5), hematocrit: 28.0 % (range 36-45), mcv (mean corpuscular volume): 92.0 fl (range 81-98), mch (mean corpuscular hemoglobin): 29.3 pg (range 27.3-33.6), mchc (mean corpuscular hemoglobin concentration): 31.9 g/dl (range 32.2-36.5), platelet count: 359.0 thou/ul (range 150-400), rdwcv (red cell distribution width): 13.9 % (range 11.6-14.4), % total neut: 70.0%, % lymphocytes: 18.0%, % monocytes: 8.0%, % eosinophils: 3.0%, %basophils: 0.0%, % immature granulocytes: 1.0%, neutrophils: 10.1 thou/ul (range 1.80-7.00), lymphocytes: 2.53 thou/ul (range 1.00-4.80), monocytes: 1.14 thou/ul (range 0.00-0.80), eosinophils: 0.38 thou/ul (range 0.00-0.50), basophils: 0.06 thou/ul (range 0.00-0.20), immature granulocytes: 0.18 thou/ul (range 0.00-0.05), nucleated rbc: 0.0 thou/ul (range 0.00), % nucleated rbc: 0.00%.Ct examination showed maxillofacial with count.Diagnosis showed worsening of orbital cellulitis.Patient states eye pain was stable with the current pain regimen, but notes that the swelling appears to be worse and thinks vision is worse as well.On (b)(6) 2020 reports left eye was swelling, redness remains the same, eye ball has a white scar in the middle surrounded by pink sclera.Patient was on hourly eye drop, started with quinolone antibiotics and aminoglycoside antibiotics q2 hours alternating with fluoroquinolone and tetracycline antibiotics.Patient was treated with 3-4mg opiate analgesics.Culture test: cultures grew occasional pseudomonas (pan sensitive).Eye and face edema seemed to improve overnight, but pupil is still white and milky, feeling better in terms of pain, vision is getting better.On (b)(6) 2020 patient was noticed hallucinations, left eye was swollen edematous and open to air.Patient was continued with iv antibiotics.Eye and face edema improved, pupil was still white and milky but says she does see some light now, pain is mostly better vision getting better.Prothrombin time: 37.3s (range 10.7-15.6) and prothrombin inr: 3.7 (range 0.8- 1.3).On (b)(6) 2020, diagnosis confirmed superficial injury of the left cornea/ trauma to left eye and corneal ulcer without endophthalmitis open globe injury.Patient was started with macrolide antibiotics, tetracycline antibiotics, anticholinergics, fluoroquinolone antibiotic iv 400mg for prophylaxis and non steroidal anti-inflammatory drug (nsaid) 1mg for pain.Prothrombin time: 38.6s (range 10.7-15.6) and prothrombin inr: 3.9 (range 0.8- 1.3).Temperature c: 36.6 degree celsius, heart rate: 75 bpm, respiratory rate: 16 br/min, sbp- noninvasive: 112 mmhg high, dbp- noninvasive: 76 mmhg, map- noninvasive: 86 mmhg.Culture test revealed fungal with stain.Patient was admitted from on (b)(6) 2020 during which she received fluoroquinolone antibiotic iv, nucleoside analogs 1g three times a day, glycopeptide antibiotics q1h, aminoglycoside antibiotics q1h while awake and q3h while sleeping until seen in clinic, broadened iv gylcopeptide antibiotics for inflammation and infection, broad spectrum penicillin + beta lactamase inhibitors for worsening erythema on 7/1, inflammation and infection.From on (b)(6) 2020 the patient was transitioned to penicillin class of antibiotics, tetracycline antibiotics for erythema and edema and anti-viral drugs 1g q8h for 14 days.On (b)(6) 2020 the patient used 20 mg corticosteroids and on (b)(6) 2020 used 10 mg corticosteroids.During discharge corneal ulcer was stable, no progress in pain.On (b)(6) 2020 patient was ongoing with corneal ulcer and orbital cellulitis due to hydrogen peroxide cleaning solution.Patient was started with quinolone and aminoglycoside antibiotics q2h, alternating with fluoroquinolone and tetracycline antibiotics.Total epi defect remains with thick infiltrate making it challenging to access thinning.Due to severe chemical injury limbal stem cell was damaged.Patient was instructed to stop glycopeptide antibiotic and aminoglycoside antibiotic and was replaced with fluoroquinolone anti-infective drugs q2h.Patient also continued with anticholinergic twice daily, corticosteroids, penicillin antibiotics, tetracycline antibiotics.Medical history showed hypertension, high-density lipoproteins and metal valve replacement.Physical examination revealed constitutional: well appearing, pleasant; psychiatric: normal mood, affect; neurologic: axox3 and no nystagmus; skin: no facial erythema, edema, rashes, abrasions; head: normocephalic, atraumatic; ent: external ears and nose are normal in appearance; respiratory: normal respiratory effort.Visual acuity (snellen- linear) dist cc: 20/30 +2 (od) and lp in (os).Tonometry pressure 12 (od), 7 (os).Pupil of od- dark: 4, light:3.5, shape: round.Reaction, slow and apd: none.Pupil of os- poor view.Slit lamp examination revealed- external: normal (ou); lids/lashes: normal (od), lides/lashes: normal (od), mild upper and lower lid edema, 1mm lag ophthalmic (os); conjunctiva/sclera: white and quite (od), 2+ diffuse chemosis, 3+ diffuse injection (os); cornea: clear (od), circumferential limbal ischemia, total epi defect with full thickness soupy neurotic infiltrate limbus to limbus; anterior chamber: deep and quiet (od), no view (os); iris: normal, no neovascularization (od), no view (os); lens: 1+ns(od), no view (os); vitreous: normal(od), no view(os); fundus examination revealed disc: no view, prior b-scan on (b)(6) with vitreous opacities.Pain was prominent in the morning but improved from prior, same pain in eye movement.Vision significantly not improved.Infection was developing.On (b)(6) 2020 stated pain slightly improved, feeling down about look of vision, broken glasses and possibility of losing vision in left eye.Improvement showed in epi defect from total epi defect to 8mm x 8mm circular defect.Patient was asked to complete the course of already prescribed medications and no new medications was prescribed.History of myopia [contact leans wearer (-4.75)].Physical examination revealed constitutional: well appearing, pleasant; psychiatric: normal mood, affect; neurologic: axox3 and no nystagmus; skin: no facial erythema, edema, rashes, abrasions; head: normocephalic, atraumatic; ent: external ears and nose are normal in appearance; respiratory: normal respiratory effort.Visual acuity (snellen- linear) dist cc: 20/30 -2 (od), dist sc lp (os).Slit lamp examination revealed- external: normal (ou); lids/lashes: normal (od), lides/lashes: normal (od), mild upper and lower lid edema, 1mm lag ophthalmic (os); conjunctiva/sclera: white and quite (od), 2+ diffuse chemosis, 3+ diffuse injection (os); cornea: clear (od), circumferential limbal ischemia, total epi defect with full thickness soupy neurotic infiltrate limbus to limbus; anterior chamber: deep and quiet (od), no view (os); iris: normal, no neovascularization (od), no view (os); lens: 1+ns (od), no view (os); vitreous: normal(od), no view(os).Refraction: sphere: -5.00 (od), -4.75 (os).Manifest refraction of od sphere: -4.75, cylinder: +0.50, axis: 090.On (b)(6) 2020 reported that she no longer feels much pain, may be just a little bit occasionally and sometimes wakes her up at night.Edema is improved and can visualize superior area of thinning.Patient was continued with fluoroquinolone anti-infective drug and corticosteroids and was instructed to stop anticholinergic.Physical examination revealed constitutional: well appearing, pleasant; psychiatric: normal mood, affect; neurologic: axox3 and no nystagmus; skin: no facial erythema, edema, rashes, abrasions; head: normocephalic, atraumatic; ent: external ears and nose are normal in appearance; respiratory: normal respiratory effort.Visual acuity (snellen- linear) dist sc: lp (os), dust cc: 20/30 (od), dist ph cc: 20/20 (od).Slit lamp examination revealed- external: normal (ou); lids/lashes: normal (od), lides/lashes: normal (ou); conjunctiva/sclera: white and quite (od), 1+diffuse chemosis, 2-3+ diffuse injection (os); cornea: clear (od), absent corneal sensation in 4/4 quadrants, circumferential limbal ischemia, 7.5 mmh x 6mm epi defect (improved from on (b)(6) 2020) with full thickness soupy neurotic infiltrate limbus to limbus, superficial and deep neovascularization 360, area superiorly of darkening severe thinning (os); anterior chamber: deep and quite (od), no view (os); iris: normal, no neovascularization (od), no view (os); lens: 1+ns(od), no view (os); vitreous: normal(od), no view(os).Fundus examination revealed disc: no view, prior b-scan on (b)(6) with vitreous opacities.On (b)(6) 2020 patient was still continuing fluoroquinolone anti-infective drug and corticosteroids.She no longer feels much pain may be just a little bit occasionally and sometimes wakes her up at night.Physical examination revealed constitutional: well appearing, pleasant; psychiatric: normal mood, affect; neurologic: axox3 and no nystagmus; skin: no facial erythema, edema, rashes, abrasions; head: normocephalic, atraumatic; ent: external ears and nose are normal in appearance; respiratory: normal respiratory effort.Visual acuity (snellen- linear) dist sc: lp (os), dust cc: 20/30 -2 (od), dist ph cc: 20/25 +2 (od).Slit lamp examination revealed- external: normal (ou); lids/lashes: normal (od), lides/lashes: normal (ou ); conjunctiva/sclera: white and quite (od), 1+diffuse chemosis, 2-3+ diffuse injection (os); cornea: clear (od), absent corneal sensation in 4/4 quadrants, circumferential limbal ischemia, 7.5 mmhx 6mm epi defect (improved from on (b)(6) 2020) with full thickness soupy neurotic infiltrate limbus to limbus, superficial and deep neovascularization 360, area superiorly of darkening severe thinning (os); anterior chamber: deep and quite (od), no view (os); iris: normal, no neovascularization (od), no view (os); lens: 1+ns(od), no view (os); vitreous: normal(od), no view(os).Fundus examination revealed disc: no view, prior b-scan on (b)(6) with vitreous opacities.On (b)(6) 2020, she was instructed to continue fluoroquinolone antibiotic and corticosteroids.No change in symptoms not much pain.Vision was better.On (b)(6) 2020 conjunctivalization most likely 2/2 lscd, paracentral inferior thinning, continued fluoroquinolone antibiotic and corticosteroids.Physical examination revealed constitutional: well appearing, pleasant; psychiatric: normal mood, affect; neurologic: axox3 and no nystagmus; skin: no facial erythema, edema, rashes, abrasions; head: normocephalic, atraumatic; ent: external ears and nose are normal in appearance; respiratory: normal respiratory effort.Visual acuity (snellen- linear) dist sc: 20/40 (od), lp (os).Tonometry pressure 15 (od), 17 (os).Slit lamp examination revealed- external: normal (ou); lids/lashes: normal (od), lides/lashes: normal (ou ); conjunctiva/sclera: white and quite (od), 1+diffuse chemosis, 2-3+ diffuse injection (os); cornea: clear (od), absent corneal sensation in 4/4 quadrants, circumferential limbal ischemia, 5.5 mm 6mm epi defect (improved from on (b)(6) 2020) with severe thinning inferiority within epi defect.Conjunctivalization 360 with superficial and deep neovascularization (os); anterior chamber: deep and quite (od), no view (os); iris: normal, no neovascularization (od), no view (os); lens: 1+ns(od), no view (os); vitreous: normal (od), no view(os); fundus examination revealed disc: no view, prior b-scan on (b)(6) with vitreous opacities.No change in symptoms not much pain.Vision was better.Additional info has been requested but not yet available.
|