Patient returns today 09/13/16 for complete exam
CC: He reports no changes to vision at this time OU. However, his glasses
are over three years old and are in poor shape. He reports good compliance with
Latanoprst. Amsler Grid is stable. He reports redness, discomfort and mattering
of his eyes.
Current Ocular Meds:
1. Latanoprost QHS OU
2. Ketotifen bid OU
Last seen 06/1/16 with for VF/IOP eval
Last complete: 11/16/15 for complete eye eval
The patient is being followed for:
1. Primary open angle glaucoma OU
2. Hypertension without retinopaty OU
3. Pseudophakia OU
4. OD choroidal nevus
5. Early nonexudative age-related macular degeneration OU
6. Myopic astigmatism c presbyopia OU
7. Allergic Conjunctivitis OU
OCULAR HX:
[+] Trauma: Hx of flashburns OU
Hx of fall x12/2014 per patient
[+] Surgery: CE IOL OU
Surgical iridectomy OD
[-] Strabismus:
[+] Glaucoma: POAG OU
[-] Flashes:
[+] Floaters: OS stable
[-] Diplopia:
FAMILY OCULAR HX:
[+]Glaucoma - Father
[-]Macular Degeneration
[-]Blindness
[-]Retinal Detachment
MED HX:
[-]DM
[-]HTN
[+]Hyperlipidemia
[-]CVA
[+]Cancer - Skin
[-]Hepatic
[-]Renal
[+]Cardiovascular - Abdominal aorta finding
[+]Respiratory - COPD
[-]Neurological
[-]Genitourinary
[+]Hemotologic - Hypokalemia, ASPIRIN 81MG
[+]Endocrine - Thyroid nodule
[+]Musculoskeletal - Degeneration of cervical intervertebral
disc, Cervical radiculopathy, DJD, Chronic low back pain
[-]Autoimmune
[+]Gastrointestinal
PSHX:
[+]Smoke - ~1/2 PPD
[+]ETOH
Current Problem List Reviewed
Current Medications Reviewed
Blood Pressure 147/77 (07/20/2016 13:50)
Diabetic Status - Lab Information
Jan 11, 2016@10:35:32 BLOOD HBA1C 5.3 % 4.5 - 6.0
GLUCOSE: 93 (01/11/16 10:35) PLASMA
Allergies - SIMVASTATIN, TRAMADOL, CYANOCOBALAMIN, HYDROCHLOROTHIAZIDE
CURRENT SPECTACLE RX & VISUAL ACUITY
OD: -0.25 -0.75 x 055 20/30-1
OS: -1.00 -0.75 x 083 20/25+1
ADD: +2.50 OU
EOM: Smooth and full w/o Diplopia/Pain
CONFRONTATION VIS FIELDS: FULL TO FINGER COUNTING OD/OS
AMSLER GRID: Normal and without distortion OU
PUPILS: PERRL without APD OU
REFRACTION AND BEST VISUAL ACUITY:
OD: -0.25 -0.50 x 085 20/25
OS: -0.75 -0.75 x 077 20/20
ADD: +2.50 OU
SLIT LAMP EXAM:
Lids/Lashes: Irregular Margins, Inspissation of glands OU
Sclera/Conj: GI hyperemia with mild papillae OU
Cornea: Arcus OU; Endo scars OU
ANTERIOR CHAMBER:
OD: Deep and quiet, (-)cells and flare
OS: Deep and quiet, (-)cells and flare
IRIS:
OD: Flat and Intact, Sup iridectomy @12:00; (-)NVI
OS: Flat and Intact, (-)NVI
TONOMETRY:
OD: 11 mmHg
OS: 13 mmHg
TIME: 1321
DILATION: 1 GTT Tropicamide (1.0%) OU & 1 GTT Phenylephrine (2.5%) OU
INTERNAL (90/78 BIO):
LENS:
OD: PCIOL, centered and clear
OS: PCIOL, centered and clear
VITREOUS:
OD: Syneresis
OS: Syneresis, PVD
NERVE:
OD: 0.45/0.50 cup/disc ratio (horiz/vert)
Normal Color/Margins
OS: 0.30/0.30 cup/disc ratio (horiz/vert)
Normal Color/Margins
MACULA:
OD: Central RPE mottling and few scattered hard drusen; (-)CNVM
~1DD flat choroidal nevus temp to mac without elevation or lipofuscin
OS: Rare RPE mottling and few scattered hard drusen; (-)CNVM
BLOOD VESSELS:
OD: Normal course and caliber
OS: Normal course and caliber
PERIPHERY:
OD: Flat and attached 360
OS: Flat and attached 360
ADDITIONAL TESTS: See testing tab
ASSESSMENT:
1. Primary open angle glaucoma OU
a. IOP today 11/13 mmHg OD/OS; Latanoprost QHS OU
-Target IOP of 16-18 mmHg OU; target met today
b. OCT 11/16/2015: Stable avg thickness OU; (+)thinning
superior>inferior OD
c. Photos 12/29/2014: stable cupping OU
d. VF 06/2016: Full, non-glaucomatous OU
e. Gonio 02/16/2016: open to CBB 360 OU
f. Pachs done 11/10/2008: CCT OD 513 / OS 532
g. GDx 04/02/2009 Nerve fiber index - baseline
OD: 55 - super/inf thinning
OS: 19 - trace sup thinning
2. Hypertension without retinopaty OU
3. Pseudophakia OU
4. Choroidal nevus OD
5. Early nonexudative age-related macular degeneration OU
6. Myopic astigmatism c presbyopia OU
7. Allergic Conjunctivitis OU
8. Dry eye Syndrome with meibomian gland dysfunction OU
PLAN:
1. Patient educated on findings and importance of follow-up
and med compliance. Continue Latanoprost QHS OU; He denies
refill needed at this time. Monitor 01/2016 Gonio/IOP eval
2. Patient educated on findings and importance of blood
pressure control. Monitor 9/2017 complete
3. Patient educated on findings and UV protection. Monitor
11/2016 complete
4. Monitor 9/2017 complete
5. Patient educated on findings and importance of follow-up.
Educated patient on at home monitoring of vision and
importance of multivitamin use, smoking cessation, and UV
protection. RTC if vision changes noted; otherwise, monitor
9/2017 complete
5. Entered Eyeglass request. Monitor 9/2017 complete or sooner
6. Patient educated; continue Ketotifen BID OU. Monitor 9/2017
7. Patient education on condition. Advised warm compresses and
lid scrubs bid OU. Continue Artificial Tears tid/prn OU.
Prescribe Bacitracin/Poly ung qhs OU. Monitor 9/2017 at
complete exam.
RTC 01/2017 Gonio/IOP eval
RTC 05/2017 VF/IOP eval
RTC 09/2017 Complete/OCT/photos