New Patient Visit Note for Ophthalmology

Date of Examination: 11/01/2024 Reason for Visit: Diagnoses: - Cataract, unspecified: H25.9 - Primary open-angle glaucoma, bilateral: H40.113 - Chief Complaint: Blurred vision in both eyes - Extended HPI: 65-year-old Caucasian male, retired engineer, referred by Dr. Smith with a past medical history of hypertension and diabetes, who presents with a complaint of progressive blurred vision over the past six months, moderate in severity, affecting daily activities. A1C: 7.2 Current Ocular Meds: Latanoprost once daily at bedtime, Timolol twice daily - Past Ocular History: Previous cataract surgery in the right eye, laser trabeculoplasty - Past Medical History: Hypertension, diabetes mellitus type 2 - Past Surgical History: Appendectomy, cataract surgery in the right eye - Systemic Meds: Metformin, Lisinopril - Allergies: NKDA - Family Ocular History: Father had glaucoma - Social History: Non-smoker, occasional alcohol use, no occupational hazards - ROS: Just click default. Objective: - Dilation: Yes - Dominant Eye: OD - Visual Acuity: Without correction OD: 20/50, OS: 20/60; With correction OD: 20/30, OS: 20/40 - Intraocular Pressure: Goldmann applanation, OD: 18 mmHg, OS: 20 mmHg - Pachymetry: Ultrasound, OD: 540 microns, OS: 550 microns - Refractions: OD: +1.00 -0.50 x 90, OS: +1.25 -0.75 x 85 Special testing: - Red Desaturation: OD: Normal, OS: Normal - TBUT: OD: 8 seconds, OS: 7 seconds - Schirmer Tear: OD: 10 mm, OS: 9 mm - External -----> General: Symmetric Appearance -----> Pupils: Round and reactive OD, OS -----> Motility: Full range of motion OD, OS -----> CVF: Full to confrontation OD, OS -----> Adnexa: No abnormalities noted OD, OS - Anterior Segment: -----> General: Clear corneal graft OD, OS -----> L/C/S: No injection, clear conjunctiva OD, OS -----> Cornea: Clear OD, OS -----> A/C: Deep and quiet OD, OS -----> Iris: Normal OD, OS -----> Lens: PCIOL in great position OD, OS - Posterior Segment: -----> General: Clear view of posterior segment OD, OS -----> Nerve: Cup to disc 0.6 OD, OS -----> Vitreous: Clear OD, OS -----> Vessels: Normal caliber OD, OS -----> Macula: No edema OD, OS -----> Periphery: Attached OD, OS Gonio: -----> Gonioscopy: Widely open to scleral spur 360 degrees OU w/no NVI/NVA noted Diagnostics: - OCT Macula: No macular edema OD, OS - OCT RNFL: Normal RNFL OD, OS - Corneal Topography: Normal study OD, OS - Fundus Photos: Confirms clinical findings OD, OS Procedures: None Impression and Plan: Diagnoses: - Cataract, unspecified: H25.9: Consider cataract surgery OS - Primary open-angle glaucoma, bilateral: H40.113: Continue Latanoprost and Timolol, monitor IOP Follow-Up: 3 months, sooner if vision worsens Patient Education: Discussed the nature of cataracts and glaucoma, treatment options, and prognosis Referrals: None Meds to be prescribed: None Patient Pharmacy: Notes to Reg: Letters: Thanks you for your Kind referral of this wonderful patient! ------------------------------------------------------------------------------------- Scheduling Call: - John Doe - 01/01/1959 - Blurred vision - 555-123-4567 - johndoe@example.com - 123 Main St, Anytown, USA - Glaucoma - Health Insurance: ABC Health - Preferred date and time for the call: 11/02/2024, 10:00 AM - Scheduled date and time for the in clinic appointment: 11/15/2024, 2:00 PM - Contact information (phone number, email): 555-123-4567, johndoe@example.com - Any specific questions or topics to be discussed during the call: Discuss cataract surgery options - Additional notes or instructions for the patient: Bring current medications to the appointment - Referring doctor: Dr. Smith - Preferred date and time for the call: 11/02/2024, 10:00 AM --------------------------------------------------------------------------- - John Doe - 01/01/1959 - Patient's MRN: 123456 - Height: 180 cm - Weight: 85 kg - Ethnicity: Caucasian - Occupation: Retired Engineer - Patient's Phone number: 555-123-4567 - Patient's Email Address: johndoe@example.com - Patient's Mailing Address: 123 Main St, Anytown, USA - Patient's health insurance information: ABC Health - Referring source: Dr. Smith - Primary care physician: Dr. Smith