Established patient returns to the triage clinic for redness/swelling of adnexa
CC: red/swolling/irritated OS, adexa and globe; adnexa is red/swollen and tender
to touch of LUL and LLL; globe is mildly red; all started yesterday; Denies any
recent illnesses/trauma
Patient also reports that room seems a little dimmer OD/OS - has been going on
for the past year - denies a dimming/blackening that occurs and then vision
comes back, appears to be more lighting dependent, says everything appears
normal in bright lighting, just with dimmer lighting everything appears dimmer
than usual
The patient was last seen 01/29/16 for complete by Dr. Munther
The patient is being followed for:
1. Refractive error (with no previous refraction at the VA)
OCULAR HX:
Pain/Discomfort Scale 1/10: 0
[-] Trauma:
[-] Surgery:
[-] Strabismus:
[-] Glaucoma:
[-] Flashes:
[-] Floaters:
[-] Diplopia:
Other:
Ocular meds: none
FAM. OC HX:
[-]Glaucoma [-]Macular Degeneration
[-]Blindness [-]Retinal Detachment
Other:
MED HX:
(-)DM
(-)HTN
(-)Hyperlipidemia
(-)CVA
(-)Cancer
(-)Hepatic
(-)Renal
(+)Cardiovascular: Anemia
(-)Respiratory
(-)Neurological
(-)Genitourinary
(-)Hematologic
(+)Endocrine: Hypothyroid
(-)Musculoskeletal
(-)Autoimmune
(-)Gastrointestinal
(+)Psychiatric: schizophrenia
(+)Other: Vitamin D deficiency, Herpes Simplex
History of noncompliance with medication regimen
Reports history of shingles around eye
PSHX:
(-)Smoke
(-)ETOH
Current Medications Reviewed
Allergies - ASPIRIN
CURRENT SPECTACLE RX:
OD: +2.75 -1.00 x 159
OS: +3.00 sphere
ADD: +1.50
VISUAL ACUITY: With Correction (through last MRx)
DIST
OD: 20/40
OS: 20/30
EOM: Smooth and full w/o Diplopia/Pain
PUPILS: PERRL: Yes; No APD OD/OS
REFRACTION AND BEST VISUAL ACUITY:
OD: +3.50 -1.00 x 151 20/30+2
OS: +2.75 sph 20/25+2
ADD: +1.50, but pt reports no improvement in VA with Add (20/60 OS, 20/30 OU)
Patient prefers
[+]Line bifocal
[+]UV400
[+]Scratch coating
[+]Tint at patient's preference
**variable refraction, patient denies changes to vision with large dioptic steps
**Requires frequent encouraging, occasional would see patient closing
eyes/almost sleeping behind phoropter, may benefit from trial frame refraction
in the future
SLIT LAMP EXAM:
Lids/Lashes:
OD: normal
OS: gr1+ edema with mild redness LUL and LLL
Sclera/Conjunctiva:
OD: tr papillae
OS: gr2 diffuse follicles inf palp conj (concentrated temporally)
gr2 diffuse bulbar injection
Cornea:
OD: gr3 diffuse SPK concentrated inferiorly and coallesqued into
sections temporal and superiorly
OS: gr1+ inf diffuse SPK
ANTERIOR CHAMBER:
OD: Deep/Dark/Quiet, no cells/flare, VH 4x4
OS: Deep/Dark/Quiet, no cells/flare, VH 4x4
IRIS:
OD: Flat and Intact, No Rubeosis
OS: Flat and Intact, No Rubeosis
TONOMETRY:
OD: 15
OS: 15
TIME: 1517
DILATION:
1 GTT Tropicamide (1.0%) OU
1 GTT Phenylephrine (2.5%) OU
INTERNAL (78, 20D BIO):
LENS:
OD: clear
OS: clear
VITREOUS:
OD: clear
OS: clear
*unsteady fixation
NERVE:
OD: 0.40/0.45 cup/disc ratio (horiz/vert)
Normal Color/Margins
OS: 0.45/0.45 cup/disc ratio (horiz/vert)
Normal Color/Margins
*unsteady fixation
MACULA:
OD: no blood, fluid or exudates
OS: no blood, fluid or exudates
*unsteady fixation
BLOOD VESSELS:
OD: normal course and caliber
OS: normal course and caliber
*unsteady fixation
PERIPHERY:
OD: No holes, tears or detachments
OS: No holes, tears or detachments
ADDITIONAL TESTS: **tested due to reduced visual acuity today**
(+) OCT: RNFL Thickness Average Analysis Report
OD: Ave 90um, all quadrants/clock hours green
OS: Ave 103um, all quadrants/clock hours green
-Impression: baseline, normal
(+) OCT: Macular Thickness Report
OD: CT 223um, normal foveal contour, no IRF/SRF
OS: CT 220um, normal foveal contour, no IRF/SRF
-Impression: baseline, normal
ASSESSMENT:
1. Viral conjunctivitis OS - new problem, additional workup required
- Clear cornea with mild superficial punctate keratitis
- No anterior chamber reaction
2. Refractive error with Hyperopic astigmatism OD and Hyperopia OS -
established problem, stable
- Patient will likely benefit from trial frame refractions
- Best corrected visual acuity 20/30+2 OD, 20/25+2 OS
- Patient motivation is a key contributing factor in exams
3. Dry eye syndrome OU - new problem, additional workup required
- Superficial punctate keratitis OD>>OS
4. Unremarkable posterior segment health OU - established problem, stable
- OCT shows healthy nerve fiber layer and macular findings OD/OS
PLAN:
1. Educated patient on condition and effects on vision/ocular comfort.
Dispensed from omnicell Tobradex for use QID OU for 1 week. Instructed patient
to shake well before each use. Patient was requesting acyclovir for infection as
well as a viral culture, educated patient that infection is likely not of a
herpetic origin. Instructed patient to return to clinic in 5 days for anterior
chamber check or sooner if vision/condition worsens or new symptoms develop.
Monitor 1 week.
2. Educated patient on stability of condition and recommended specs for full
time wear. Educated about adaptation to new specs. Due to history of variable
refractions, patient will likely benefit from trial frame refraction in the
future. Dispensed hard copy of prescription for patient to fill outside the VA
if desired. Monitor yearly.
3. Educated patient on condition and effects of unstable tear film on vision.
No artificial tears prescribed at this time due to #1. Consider prescribing at
anterior segment follow-up in 1 week. Monitor sooner if condition worsens.
4. Educated patient on stability of condition and emphasized the importance of
yearly dilated eye exams. Monitor 1 year.
RTC 12/06/17 for anterior segment evaluation for #1 and #3.