Tuesday, May 24, 2011

Gradual Blurred Vision OU for 6 months

Age / Race / Gender: 47 year old black female
Chief Complaint: Blurry vision OU
Onset: Gradual over the last 6 months.
Location: OU
Severity: mild
Duration: 6 months to a year.
Relieving Factors: Glasses help but need updating.
Patient Ocular History: Last eye exam 3 years prior.  Patient received bifocal glasses.
Family Ocular History: (-) Glaucoma.  
Patient Medical History
  • DM type 2 for 8 years.  Blood sugar levels and HbA1c unknown.   
  • Hypertension for 2 years. 
  • Last Physical exam 1 year prior.  Patient reported normal results and good health.  
Family Medical History: (+) DM type 2. Father, HTN Father.
Review of Systems: Within normal limits
Clinical Findings: BCVA: 20/40 OD, 20/25 OS
Pupils: WNL (-) APD
Conf Fields: Full to finger counting OU
IOP: 17mmHg OD,  16mmHg OS.
Slit Lamp: Anterior segment is clear and WNL, (-) NVI.  Lens was clear.
Dilated Fundus Exam: See Photos below

OD

OS
See the comments for assessment and plan

Monday, May 23, 2011

I was driving to work when I suddenly couldn't see

Age / Race / Gender: 36 year old white female
Chief Complaint: Sudden loss of vision OD
Onset: This AM while driving to work.
Location: Right field of vision
Severity: Moderate
Duration: Started 45 min prior
Relieving Factors: None
Patient Ocular History: No significant history
Family Ocular History: Non-Contributory
Patient Medical History:
  • Patient is currently 6 months pregnant without complications.
  • No HTN
  • No DM
Family Medical History: Non-contributory
Review of Systems: Within normal limits
Clinical Findings: VA: 20/20 OU
Pupils: WNL (-) APD
Conf Fields: Temporal Restriction OD.
IOP: 16mmHg OU
Slit Lamp: WNL
Non-Dilated Retinal View: WNL
See Visual Fields Below:
OS: 9:41am
OD 9:31am
OD: 11:01am
OD: 1:55pm


See the Comments for the Assesment and Plan.


Sunday, May 22, 2011

Blurred vision in the left eye for 2 weeks

Age / Race / Gender: 55 year old hispanic male
Chief Complaint: Blurry vision OS
Location: OS
Severity: Sever
Duration: 2 weeks
Relieving Factors: none
Patient Ocular History: First eye exam with no previous ocular Hx.
Family Ocular History: Unremakrable
Patient Medical History: Mild HTN and type 2 Diabetes since 2008.
Family Medical History: Non-contributory
Review of Systems: unremarkable
Clinical Finding: 
  • BCVA: 20/20 OD, 20/200 OS
  • EOM: Normal
  • Pupils: Mild APD OS
  • Conf Fields: Full OD, Restricted OS
  • IOP: 15mmHg OU with applination
  • Slit Lamp: Small Corneal scars OU secondary to weld splatter. 
  • BP: 118/79mmHg in office
  • Pulse: 67 bpm
  • Dilated exam: See Photos



Retina OD
Retina OS
OCT OS



The assessment and plan are located in the comments section.