OPTHALMOLOGY FILES

OPTHALMO_2

CHART NOTE

The patient comes in today for eye check.  Patient has newly discovered diabetes mellitus and complaints of impaired vision.

On physical exam today blood pressure is 220/114, checked twice, with pulse of 72 beats per minute.  Snellen test was done, and without glasses vision was 20/40 on the left and 20/40 on the right.  Pupils were PERRLA.  Cranial nerves appeared intact.  Bilateral mature cataracts were noted.  Evaluation of the disks of her eyes was hampered by constriction of the pupils; however, some mild arteriolar narrowing could be detected.  Funduscopy was inadequate because of the brisk pupillary constriction.

ASSESSMENT

1.  Impaired visual acuity secondary to cataracts and possibly effects from diabetes mellitus.

2.  Markedly elevated hypertension.  She was advised to seek prompt medical attention for this.

CHART NOTE

The patient’s mother brings this 8-year-old boy in for outward deviation of both eyes.  Apparently the child was operated on at age 2 for strabismus, but no records are available to me regarding this.

Examination revealed conjunctival scarring over the medial recti bilaterally, so I presume the patient underwent bilateral medial rectus recessions.  Best corrected visual acuity was 20/20 OU.  His pupils were essentially normal.

He demonstrated 18 prism diopters of exotropia at distance which decreased to 8 to 10 diopters or exotropia at near.  He was unable to demonstrate any sterio acuity on testing, and on 4-dot he suppressed the right eye at a distance but was able to fuse at near.  Slit-lamp examination was significant only for scarring of conjunctive medially.  Ophtalmoscopic exam was normal.

ASSESSMENT:  Exotropia with overacting inferior obliques.

FOOTNOTE

Lines 7-8.  Pupils were PERRLA is redundant.  PERRLA means Pupils were equal, round, reactive to light and accommodation.

Line 24.  The redundant statement His pupils were essentially normal was deleted.

Line 25.  Alternative:  8-10.

OPTHALMO_3

INITIAL OFFICE EVALUATION

This 80-year-old woman developed decreased visual acuity 2 years ago after being hospitalized for asthma.

A diagnosis of macular degeneration was made sometime after this.  The left side is worse than the right.  She has otherwise been relatively healthy except for a long history of asthma.

MEDICATIONS:  Theo-Dur, Proventil, Zantac, and past history of prednisone.

PAST MEDICAL HISTORY:  Hospitalized for asthma.  Had peptic ulcer at the same time.

ALLERGIES:  None known.

REVIEW OF SYSTEMS:  Unremarkable.

FAMILY HISTORY:  Negative.

HABITS:  Drinks coffee and 1 alcoholic beverage.  Diet:  Skips meals but otherwise balanced.

EXAMINATION:  Blood pressure 150/96, which is typical for her.  Pulse 100.  Heart and lungs okay.  Eye exam not done.

ASSESSMENT

1.  Macular degeneration.

2.  Asthma.

3.  History of peptic ulcer.

4.  Polypharmacy.

PLAN:  Will use macular degeneration protocol at lower dose initially.  Gave I.V. 7 cc of selenium with additional 5 cc bacteriostatic water.  Tolerated well.  Will repeat another 7 times before assessing possible benefit.

OPTHALMO_4

INITIAL OFFICE EVALUATION

This patient is a 21-year-old male who came in to the clinic complaining of blurred vision in his right eye.  He has a 9-year history of IDDM.  Vision is 20/20 in the left and 20/30 in the right.  Other complaints include frequent frontal headaches and blurring of writing on the blackboard.  Last eye exam was 4 years ago.

Physical exam was routine except for visualization by direct ophthalmoscope revealing numerous hard exudates and probable macular edema.

Recommendations include referral for background retinopathy to an ophthalmologist for dilated fundus exam, possible fluorescein angiography, and probable focal argon laser photocoagulation.