INITIAL OFFICE EVALUATION
This 80-year-old woman developed decreased visual acuity 2 years ago after being hospitalized for asthma. A diagnosis of macular degeneration was made sometime after this. The left side is worse than the right. She has otherwise been relatively healthy except for a long history of asthma.
MEDICATIONS
Theo-Dur, Proventil, Zantac, and past history of prednisone.
PAST MEDICAL HISTORY
Hospitalized for asthma. Had peptic ulcer at the same time.
ALLERGIES
None known.
REVIEW OF SYSTEMS
Unremarkable.
FAMILY HISTORY
Negative.
HABITS
Drinks coffee and 1 alcoholic beverage. Diet: Skips meals but otherwise balanced.
EXAMINATION
Blood pressure 150/96, which is typical for her. Pulse 100. Heart and lungs okay. Eye exam not done.
ASSESSMENT
1. Macular degeneration.
2. Asthma.
3. History of peptic ulcer.
4. Polypharmacy.
PLAN
Will use macular degeneration protocol at lower dose initially. Gave I.V. 7 cc of selenium with additional 5-cc bacteriostatic water. Tolerated well. Will repeat another 7 times before assessing possible benefit.
FOOTNOTE
Line 32. Exam was expanded to Examination in the heading.
Line 44. Alternative: IV.
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