Patient returns on consult from the FHARB ward for a complete exam ^
CC: Patient reports blurred vision at near only OU. No flashes/floaters, no
diplopia. Patient notes she uses +2.50 OTC glasses for distance and
near, didnt bring with her today
The patient was last seen 12/11/13 with Dr. Chitluri for an undilated exam
The patient has yet to be dilated or refracted at Chillicothe VAMC
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
PSHX:
(-)Smoke
(-)ETOH
Current Medications Reviewed
Allergies - ASPIRIN
Blood Pressure - Refused (01/26/2016 20:35)
HbA1c - 5.4 (03/18/15)
Glucose - 93 (03/18/15)
CURRENT SPECTACLE RX: uses OTC +2.50, didn't bring them today
VISUAL ACUITY: Without Correction
DIST PH
OD: 20/60+2 20/30
OS: 20/60 20/30-2
*patient uncooperative; needed encouragement with reading letters*
COVER TEST: D: Ortho sc
EOM: Smooth and full w/o Diplopia/Pain
CONFRONTATION VIS FIELDS: FULL TO FINGER COUNTING OU
PUPILS: PERRL: Yes APD: [-]
AUTOREFRACTION:
OD: +2.87 -1.37 x 173
OS: +3.62 -0.25 x 070
REFRACTION AND BEST VISUAL ACUITY:
OD: +2.75 -1.00 x 159 20/25
OS: +3.00 sphere 20/30+2
ADD: +1.50 20/25-1
In Trial Frame re-measured acuities:
OD: 20/20-2
OS: 20/20-2
*Had to encouarge patient to read letters, gave up easily.
FINAL RX:
OD: +2.75 -1.00 x 159
OS: +3.00 sphere
Patient prefers
[+]Single Vision Distance
[+]UV400
[+]Scratch coating
[+]Tint at patient's preference
SLIT LAMP EXAM:
Lids/Lashes: clear OU
Sclera/Conj: melanosis OU
Cornea: clear OU
ANTERIOR CHAMBER:
OD: Deep/Dark/Quiet
OS: Deep/Dark/Quiet
IRIS:
OD: Flat and Intact, No Rubeosis
OS: Flat and Intact, No Rubeosis
TONOMETRY:
OD: 13 mmHg
OS: 13 mmHg
TIME: 01:23
DILATION: 01:25
1 GTT Tropicamide (1.0%) OU
1 GTT Phenylephrine (2.5%) OU
INTERNAL (78, 20D BIO): views were fleeting as patient had difficulty keeping
eyes open and cooperating with where to look
LENS:
OD: clear
OS: clear
VITREOUS:
OD: clear
OS: clear
NERVE:
OD: 0.30/0.30 cup/disc ratio (horiz/vert)
Normal Color/Margins
OS: 0.35/0.35 cup/disc ratio (horiz/vert); smaller nerve size OS
Normal Color/Margins
MACULA:
OD: no blood, fluid or exudates
OS: no blood, fluid or exudates
BLOOD VESSELS:
OD: normal course and caliber
OS: normal course and caliber
PERIPHERY:
OD: No holes, tears or detachments
OS: No holes, tears or detachments
**Patient did not display extreme behavior as previously noted from 12/11/13,
however, patient was not willing/able to keep attention during slit lamp
evaluation which inhibited prolonged views. Patient was also mildly sedated,
but still alert/oriented to time and place**
ADDITIONAL TESTING: None
ASSESSMENT:
1. Hyperopic astigmatism OD,; Hyperopia OS
2. Unremarkable anterior and posterior ocular health OU
PLAN:
1. Educated patient on findings and adaptation, new single vision distance
prescription sent to VA optical; monitor 01/2017
2. Educated patient on findings and follow-up; RTC if changes in vision
arise or flashes/floaters/vision loss occurs. Monitor 01/2017 complete
RTC 01/2017 complete