OPTHALMOLOGY TEST FILES

OPTHALMO_T1

Ophthalmology

HISTORY AND PHYSICAL EXAMINATION

PREOPERATIVE DIAGNOSES

1.  Cataract of left eye.

2.  Pseudophakia of the right eye.

3.  Dermatomyositis.

4.  Rheumatoid arthritis.

HISTORY OF PRESENT ILLNESS:  Patient is a 71-year-old woman who had an uncomplicated cataract extraction with lens implant of the right eye and had a good improvement in her visual function.  She is also bothered by blurred vision from a cataract in the left eye and enters for a similar procedure on the left eye.  She has had dry eyes and uses artificial tears frequently.  She has had ectropion repair of the right lower lid.  She has had dermatomyositis and rheumatoid arthritis for many years and has used cortisone for this.

She is presently taking Persantine twice daily and Inderal 40 mg twice daily.  She is allergic to penicillin, aspirin, codeine, and does not tolerate Tylenol because of constipation.

PHYSICAL FINDINGS

VITAL SIGNS:  Blood pressure 110/80, pulse 76 and regular.

HEENT:  Recent eye examination showed best vision of 20/50+ in the right eye and 20/200 in the left.  Pupils and extraocular motility were normal.

Intraocular pressures were 18.  Slit-lamp examination showed the eyelids in good position with weakness of the orbicularis and facial muscles.  There was a clear corneal epithelium and the normal pseudophakia of the right eye and a dense nuclear cataract on the left.  Fundus examination in each eye was normal.

Tympanic membranes are normal.

The oral cavity showed dentures in place.  The pharynx had no lesions.  The neck showed a slight right carotid bruit, and the left was normal.

CHEST:  The chest was clear to auscultation.

HEART:  Heart had a regular sinus rhythm without murmur.

EXTREMITIES:  Extremities showed ulnar deviations of the hands and mild ecchymoses in the legs.

PLAN:  Plan is a cataract extraction with lens implant of the left eye under local anesthetic as an outpatient.  The risks of the procedure, including possible loss of the eye, were discussed.

OPTHALMO_T2

Ophthalmology

DISCHARGE SUMMARY

HISTORY OF THE PRESENT ILLNESS:  The patient is 85-year-old white male who underwent scleral buckling of the left eye for retinal detachment in December and again in February.  A second scleral buckling operation was complicated by subretinal hemorrhage at the time of release of subretinal fluid.  The subretinal hemorrhage reabsorbed.  The patient did well until 2 weeks prior to admission, when he noted he could not see from the left eye.

Examination showed recurrence of the retinal detachment with an open retinal break at about the 5:30 position.

PAST OCULAR HISTORY:  The left eye underwent cataract extraction with placement of an iris-fixated lens in the past.  The patient has had corneal edema of the left eye, more pronounced after each scleral buckling procedure.  He uses topical sodium chloride agents for the corneal edema.  The history of the right eye is that there is age-related macular degeneration.

PAST MEDICAL HISTORY:  The patient has non-Hodgkin lymphoma, currently in remission.  He has had splenectomy.  He has had a tonsillar carcinoma treated surgically and with radiotherapy.  There is mild hypertension.

Current medications include allopurinol 300 mg daily, Tagamet 400 mg q.h.s., multivitamins daily, vitamin C, and the previously described topical agents for the left eye.

PHYSICAL EXAMINATION:  Vision 20/60 in the right eye and the detection of hand motion in the left eye.

Intraocular pressure was normal in each eye.

Examination of the right eye showed mild lens changes and macular scar.  Examination of the left eye showed ptosis of the upper lid and malpositioning of the lower lid.  There was evidence of previous ocular surgery.  Slit-lamp examination showed aphakia with an iris-fixated lens.  There was corneal edema and thickening present.  Fundus examination showed total retinal detachment with the evidence of a previously placed scleral buckle from about 2 to 10 o’clock, reinforced with a radial sponge at 5 o’clock, and an open retinal break at about 5:30.

LABORATORY DATA:  CBC:  There was mild elevation of the white blood count and slight reduction of the red count.  There was also reduced hemoglobin and hematocrit.  Urinalysis was negative.  Blood chemistries, including electrolytes, glucose, and BUN, were normal.  Chest x-ray showed mild changes consistent with obstructive pulmonary disease but no acute changes.  ECG showed right ventricular conduction defect and a left axis deviation.

HOSPITAL COURSE:  Under general anesthesia, the scleral buckle was revised by removing the radial element at about 5 o’clock and replacing it with a trimmed #507 implant placed circumferentially.  This resulted reinforcement of the buckle from about 4:30 to 6 o’clock, closing the retinal break.  A vitrectomy was also performed through the pars plana.  A gas-fluid exchange was performed, first using air, intravitreal and subretinal cannulated fluid extrusion.  A 30% mixture of expansile gas was then placed in the vitreous cavity.  A previously placed #276 silicone implant and #40 band were left in situ.  The buckle extended from 2 to 10 o’clock.

Postoperatively, the retina was reattached, and the patient was discharged from the hospital to be followed as an outpatient.  Discharge medications included a cycloplegic agent and topical antibiotics with sodium chloride to the left eye.

FINAL DIAGNOSES

1.  Retinal detachment, left eye.

2.  Pseduophakia, left eye.

3.  Corneal edema, left eye.

4.  Macular degeneration, right eye.

OPERATION:  Revision of scleral buckle, vitrectomy, air-gas-fluid exchange.

OPTHALMO_T3

Ophthalmology

HISTORY AND PHYSICAL EXAMINATION

DIAGNOSES

1.  Cataract of left eye.

2.  Pseudophakia of the right eye.

3.  Hypertension.

HISTORY OF THE PRESENT ILLNESS:  Patient is a 67-year-old woman who had an uncomplicated cataract extraction with lens implant of the right eye and had a good visual result.  She is bothered by blurred vision from a cataract on the left eye and desires an improvement in vision.  She added this cataract distraction for lens implant of the left eye.  She enters for cataract extraction with lens implant of the left eye.  She has had a mild amblyopia, although had best correctable vision of 20/40.

PAST HISTORY:  She is being treated for hypertension.  She takes Aldoril and, in addition, started Lasix 40 mg daily.  She takes Tagamet for ulcer disease.  She has arthritis, requires infrequent Kenalog injections, and thyroid 0.3 mg daily.  Prior surgery includes an appendectomy, tubal ligation, cholecystectomy, and a fusion procedure on the right hand.  She has many allergies, including pencillin, Keflex, iodine ,IVP dyes, Betadine, aspirin, and nonsteroidal analgesics.

REVIEW OF SYSTEMS:  Review of systems revealed a history of easy bruising but no bleeding.  No reactions to anesthetics.

Cardiopulmonary:  No shortness of breath, asthma, or angina.  Gastrointestinal Review:  Normal bowel habits.  Genitourinary:  No dysuria.

PHYSICAL FINDINGS

VITAL SIGNS:  Blood pressure 180/95, pulse 80 and regular.

EYES:  Recent eye examination showed best vision of 20/25 in the right eye and 20/80 minus in the left.  Pupils and extraocular motility and visual field by confrontation are normal.

Slit-lamp exam of the right eye showed a normal pseudophakia, and the left eye had a normal cornea and endothelium, and there was a dense nuclear and central posterior subcapsular cataract.  Intraocular pressure was 15 in the right eye and 17 in the left, and dilated fundus examination in each eye was normal.

EARS, NOSE, AND THROAT:  Tympanic membranes were normal.  The oral cavity should dentures in place, and the pharynx had no lesions.

NECK:  The neck had normal carotids without bruits.

CHEST:  Chest was clear to auscultation.

HEART:  Heart had a regular sinus rhythm without murmur.

PLAN:  Plan is a cataract extraction with lens implant of the left eye under local anesthetic as an outpatient.  She understands the major risks, such as loss of the eye, and that an implant may not be done because of surgical problem.