Ophthalmology Study

HISTORY AND PHYSICAL EXAMINATION

PREOPERATIVE DIAGNOSES

1. Cataract of left eye.

2. Pseudophakia of the right eye.

3. Dermatomyositis.

4. Rheumatoid arthritis.

HISTORY OF PRESENT ILLNESS

Patient is a 71-year-old woman who had an uncomplicated cataract extraction with lens implant of the right eye and had a good improvement in her visual function.  She is also bothered by blurred vision from a cataract in the left eye and enters for a similar procedure on the left eye.  She has had dry eyes and uses artificial tears frequently.  She has had ectropion repair of the right lower lid.  She has had dermatomyositis and rheumatoid arthritis for many years and has used cortisone for this.

She is presently taking Persantine twice daily and Inderal 40 mg twice daily.  She is allergic to penicillin, aspirin, codeine, and does not tolerate Tylenol because of constipation.

PHYSICAL FINDINGS

VITAL SIGNS:  Blood pressure 110/80, pulse 76 and regular.

HEENT:  Recent eye examination showed best vision of 20/50+ in the right eye and 20/200 in the left.  Pupils and extraocular motility were normal.  Intraocular pressures were 18.  Slit-lamp examination showed the eyelids in good position with weakness of the orbicularis and facial muscles.  There was a clear corneal epithelium and the normal pseudophakia of the right eye and a dense nuclear cataract on the left.  Fundus examination in each eye was normal.  Tympanic membranes were normal.  The oral cavity showed dentures in place.  The pharynx had no lesions.  The neck showed a slight right carotid bruit, and the left was normal.

CHEST:  The chest was clear to auscultation.

HEART:  Heart had a regular sinus rhythm without manner.

EXTREMITIES:  Extremities showed ulnar deviations of the hands and mild ecchymoses in the legs.

PLAN

Plan is a cataract extraction with lens implant of the left eye under local anesthetic as an outpatient.  The risks of the procedure, including possible loss of the eye, were discussed.

FOOTNOTE

Line 7.  In a preoperative History and Physical Examination, a Preoperative Diagnosis is sometimes dictated instead of an Admitting Diagnosis, Chief Complaint, or Impression.

Lines 27-42.  Subheadings were added in the Physical Examination.

Lines 29, 30.  Twenty fifty plus was transcribed 20/50+, and twenty two hundred was translated 20/200.