New Ophthalmology Patient Visit Note

Date of Examination: 10/24/2023

Reason for Visit:

Diagnoses:

1. Age-related nuclear cataract, bilateral (H25.13)
2. Primary open-angle glaucoma, mild stage, bilateral (H40.1131)
3. Dry eye syndrome of bilateral lacrimal glands (H04.123)

• Chief Complaint: Progressive blurry vision OU, worse with night driving, and mild foreign body sensation OU.

• Extended HPI: 68 year old Caucasian male retired accountant referred by Dr. Sarah Jenkins with a past medical history of hypertension, hyperlipidemia, benign prostatic hyperplasia, and type 2 diabetes mellitus who presents with gradual onset, progressive blurry vision and glare over the past 8 months, moderate in severity, affecting distance and night driving OU, alongside intermittent gritty sensation OU.

A1C: 6.8 %

Current Ocular Meds: Latanoprost 0.005 % ophthalmic solution 1 drop OU QHS, carboxymethylcellulose 0.5 % (Refresh Tears®) 1 drop OU PRN.

• Past Ocular History: Presbyopia, mild dry eye syndrome, POAG diagnosed 2 years ago managed with topical therapy.

• Past Medical History: Hypertension, hyperlipidemia, T2DM without retinopathy, BPH.

• Past Surgical History: Laparoscopic cholecystectomy (2015), right inguinal hernia repair (2019).

• Systemic Meds: Lisinopril 10 mg PO daily, atorvastatin 20 mg PO daily, metformin 500 mg PO BID, tamsulosin (Flomax®) 0.4 mg PO daily.

• Allergies: Penicillin (maculopapular rash), sulfa antibiotics (hives).

• Family Ocular History: Maternal glaucoma, paternal cataract extraction.

• Social History: Former smoker (quit 20 years ago), social alcohol use (1-2 glasses of wine per week), no occupational ocular hazards.

• ROS: Negative for constitutional, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, neurological, and psychiatric symptoms except as noted in HPI.

Objective

• Dilation: Yes

• Dominant Eye: OD: Dominant, OS: Non-dominant

• Visual Acuity: OD: sc 20/60, cc 20/40 (PH 20/30); OS: sc 20/50, cc 20/30 (PH 20/25)

• Intraocular Pressure: Goldmann applanation tonometry: OD: 15 mmHg, OS: 16 mmHg at 10:15

• Pachymetry: Ultrasonic pachymetry: OD: 545 microns, OS: 548 microns

• Refractions: OD: -1.75 +0.75 x 090, OS: -1.50 +0.50 x 085

Special Testing

• Red Desaturation: OD: Normal, OS: Normal
• TBUT: OD: 6 seconds, OS: 7 seconds
• Schirmer Tear: OD: 8 mm, OS: 9 mm

External

• General: OD: Symmetric Appearance, No Evidence of Infection; OS: Symmetric Appearance, No Evidence of Infection

• Pupils: OD: Round and reactive to light, no APD; OS: Round and reactive to light, no APD

• Motility: OD: Full and smooth in all gazes; OS: Full and smooth in all gazes

• CVF: OD: Full to finger counting; OS: Full to finger counting

• Adnexa: OD: Mild dermatochalasis, 1+ Meibomian Inspissation; OS: Mild dermatochalasis, 1+ Meibomian Inspissation

Anterior Segment

• General: OD: No Evidence of Infection; OS: No Evidence of Infection

• L/C/S: OD: 1+ meibomian gland dysfunction, trace nasal pinguecula, white and quiet conjunctiva; OS: 1+ meibomian gland dysfunction, white and quiet conjunctiva

• Cornea: OD: Trace inferior SPK, mild arcus senilis, clear stroma, no guttata; OS: Trace inferior SPK, mild arcus senilis, clear stroma, no guttata

• A/C: OD: Deep and quiet, no cell or flare; OS: Deep and quiet, no cell or flare

• Iris: OD: Normal architecture, no rubeosis or transillumination defects, poor dilation secondary to systemic tamsulosin; OS: Normal architecture, no rubeosis or transillumination defects, poor dilation secondary to systemic tamsulosin

• Lens: OD: 2+ nuclear sclerosis, 1+ cortical spoking; OS: 2+ nuclear sclerosis

Posterior Segment

• General: OD: Examined with 90D lens, clear media aside from lenticular changes, no diabetic retinopathy; OS: Examined with 90D lens, clear media aside from lenticular changes, no diabetic retinopathy

• Nerve: OD: C/D 0.65, distinct margins, mild inferior rim thinning, no NVD or hemorrhage; OS: C/D 0.60, distinct margins, healthy rim, no NVD or hemorrhage

• Vitreous: OD: Syneresis, PVD with Weiss ring, no hemorrhage; OS: Syneresis, clear, no hemorrhage

• Vessels: OD: Normal caliber and distribution, mild AV nicking; OS: Normal caliber and distribution, mild AV nicking

• Macula: OD: Flat, intact foveal reflex, no CME, drusen, or exudates; OS: Flat, intact foveal reflex, no CME, drusen, or exudates

• Periphery: OD: Attached 360 degrees, no holes, tears, or traction; OS: Attached 360 degrees, no holes, tears, or traction

Gonio

• Gonioscopy: Widely open angles to the scleral spur 360 degrees OU without NVI/NVA, 1+ trabecular meshwork pigmentation OU.

Diagnostics

• OCT Macula: OD: Normal foveal contour, no intraretinal or subretinal fluid, intact ellipsoid zone; OS: Normal foveal contour, no intraretinal or subretinal fluid, intact ellipsoid zone.

• OCT RNFL: OD: Mild inferior RNFL thinning (78 microns average), stable; OS: Borderline inferior RNFL thickness (82 microns average).

• IOL Master: Good-quality measurements obtained today OU for cataract surgery planning.

• HVF 24-2: OD: Reliable study, early superior nasal step; OS: Reliable study, full field without significant scotoma.

• Schirmer Tear: 7 mm at 5 min without proparacaine OD, 8 mm at 5 min without proparacaine OS.

Procedures

Punctal Plugs: Silicone punctal plugs inserted into bilateral lower lid puncta (OD and OS) without complication.

Impression and Plan

Diagnoses:

1. Age-related nuclear cataract, bilateral (H25.13): Visually significant OD > OS. Proceed with phacoemulsification with IOL implantation OD; note history of tamsulosin use (IFIS precautions required).
2. Primary open-angle glaucoma, mild stage, bilateral (H40.1131): IOP controlled on current monotherapy. Continue latanoprost 0.005 % OU QHS; consider combined MIGS (iStent) at the time of cataract surgery OD.
3. Dry eye syndrome of bilateral lacrimal glands (H04.123): Placed bilateral lower lid punctal plugs today. Continue preservative-free artificial tears QID OU to optimize ocular surface prior to final biometry/surgery.

• Visually significant cataract vs. refractive error; glaucomatous optic neuropathy vs. physiological cupping.

Follow-Up: Return to clinic in 3-4 weeks for pre-operative cataract evaluation, repeat surface check, and surgical scheduling OD. Return sooner if experiencing acute vision loss, eye pain, or flashes/floaters.

Patient Education: Discussed cataract progression, surgical risks, benefits, and alternatives, including potential intraoperative floppy iris syndrome (IFIS) related to tamsulosin. Reviewed glaucoma stability and importance of medication adherence.

Referrals: Refer to PCP (Dr. Sarah Jenkins) for routine pre-operative medical clearance prior to cataract extraction.

Meds to be prescribed: Latanoprost 0.005 % ophthalmic solution, OU, 1 drop QHS, ongoing; moxifloxacin 0.5 % ophthalmic solution, OD, 1 drop QID, starting 3 days prior to scheduled surgery.

Patient Pharmacy

CVS Pharmacy #4821, 450 Main Street, White Plains, NY 10601

Notes to Reg

Schedule for Pre-Op Cataract Evaluation OD with Surgical Coordinator in 3 weeks. Ensure medical clearance request is faxed to Dr. Sarah Jenkins.

Letters

Thank you for referring this patient.

Scheduling Call

• Robert Arthur Miller

• 14/05/1955

• Schedule new patient ophthalmology evaluation for blurry vision and glaucoma management

• (914) 555-0148

• r.miller55@email.mock

• 128 Oakwood Avenue, White Plains, NY 10605

• Cataracts and Primary Open-Angle Glaucoma

• Medicare Part B (ID: 4829-T84-9912) / AARP Supplemental

• 18/10/2023 at 14:00

• 24/10/2023 at 10:00

• (914) 555-0148 / r.miller55@email.mock

• Discuss surgical options for cataracts and review current glaucoma drop regimen

• Patient takes Flomax (tamsulosin); advise patient to bring current glasses to appointment

• Dr. Sarah Jenkins

• 18/10/2023 at 14:00

• Robert Arthur Miller

• 14/05/1955

• Patient's MRN: 849-204-11

• Height: 178 cm

• Weight: 84 kg

• Ethnicity: Caucasian

• Occupation: Retired Accountant

• Patient's Phone number: (914) 555-0148

• Patient's Email Address: r.miller55@email.mock

• Patient's Mailing Address: 128 Oakwood Avenue, White Plains, NY 10605

• Patient's health insurance information: Medicare Part B (ID: 4829-T84-9912)

• Referring source: Individual (Dr. Sarah Jenkins, MD - Internal Medicine)

• Primary care physician: Dr. Sarah Jenkins, MD