Reason for Visit:
- Patient presents for a follow-up visit to assess progress in concussion recovery, reporting ongoing visual symptoms.
Visual History:
- Patient reports intermittent blurriness, especially when reading, and occasional headaches after prolonged visual tasks.
- Symptoms began approximately two weeks ago, following a sports-related concussion. The blurriness and headaches have fluctuated in intensity, with some days being better than others.
- Patient has worn glasses for myopia since age 10. Current prescription is -2.50 in both eyes. Glasses have provided clear vision until the onset of concussion symptoms.
Medical History:
- No relevant chronic medical conditions.
- Currently taking ibuprofen as needed for headaches.
- No known allergies.
Progress Since Last Encounter:
- Patient reports a slight improvement in visual clarity and a reduction in headache frequency since the last visit.
Lifestyle Assessment:
- Patient is a student and spends several hours daily reading and using digital devices for schoolwork.
- Patient uses digital screens for several hours a day.
- Patient is not exposed to any environmental factors.
Today's Therapy Session and Results of Binocular Vision and Eye Movement Programs:
- Patient tolerated the therapy session well, with only mild reports of eye strain towards the end of the session.
- Patient demonstrated improved eye tracking and convergence abilities during the therapy exercises.
Other Relevant Issues:
- No comments from other providers.
- No changes to medications.
- No new injuries or symptoms since last visit.
Assessment:
- Post-concussion visual syndrome.
Management Plan:
- Continue current glasses prescription.
- Continue binocular vision therapy exercises at home and in-office.
- Follow-up appointment scheduled in 4 weeks.
- Patient was advised to take frequent breaks when using digital devices.
- Patient was advised to return sooner if symptoms worsen.
- Next appointment scheduled for 1 December 2024.
Patient Education:
- Patient was advised to take frequent breaks when using digital devices.
- Patient was advised to return sooner if symptoms worsen.
- Patient was instructed on proper eye hygiene and the importance of regular breaks.
Any Additional Recommendations:
- Patient was advised to take frequent breaks when using digital devices.
- Patient was advised to return sooner if symptoms worsen.
