CHART NOTE
The patient comes in today for eye check. Patient has newly discovered diabetes mellitus and complaints of impaired vision.
On physical exam today blood pressure is 220/114, checked twice, with pulse of 72 beats per minute. Snellen test was done, and without glasses vision was 20/40 on the left and 20/40 on the right. Pupils were PERRLA. Cranial nerves appeared intact. Bilateral mature cataracts were noted. Evaluation of the disks of her eyes was hampered by constriction of the pupils; however, some mild arteriolar narrowing could be detected. Funduscopy was inadequate because of the brisk pupillary constriction.
ASSESSMENT
1. Impaired visual acuity secondary to cataracts and possibly effects from diabetes mellitus.
2. Markedly elevated hypertension. She was advised to seek prompt medical attention for this.
CHART NOTE
The patient’s mother brings this 8-year-old boy in for outward deviation of both eyes. Apparently the child was operated on at age 2 for strabismus, but no records are available to me regarding this.
Examination revealed conjunctival scarring over the medial recti bilaterally, so I presume the patient underwent bilateral medial rectus recessions. Best corrected visual acuity was 20/20 OU. His pupils were essentially normal. He demonstrated 18 prism diopters of exotropia at distance which decreased to 8 to 10 diopters or exotropia at near. He was unable to demonstrate any stereo acuity on testing, and on 4-dot he suppressed the right eye at a distance but was able to fuse at near. Slit-lamp examination was significant only for scarring of conjunctive medially. Ophthalmoscopic exam was normal.
ASSESSMENT
Exotropia with overacting inferior obliques.
FOOTNOTE
Lines 12-13. Pupils were PERRLA is redundant. PERRLA means Pupils were equal, round, reactive to light and accommodation.
Line 36. The redundant statement His pupils were essentially normal was deleted.
Line 37. Alternative: 8-10.
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