Ophthalmology Study

HISTORY AND PHYSICAL EXAMINATION

DIAGNOSES

1. Cataract of left eye.

2. Pseudophakia of the right eye.

3. Hypertension.

HISTORY OF THE PRESENT ILLNESS

Patient is a 67-year-old woman who had an uncomplicated cataract extraction with lens implant of the right eye and had a good visual result.  She is bothered by blurred vision from a cataract on the left eye and desires an improvement in vision.  She enters for cataract extraction with lens implant of the left eye.  She has been bothered by glare with the left eye.  She has had a mild amblyopia, although had best correctable vision of 20/40.

PAST HISTORY

She is being treated for hypertension.  She takes Aldoril and, in addition, started Lasix 40 mg daily.  She takes Tagamet for ulcer disease.  She has arthritis, requires infrequent Kenalog injections, and takes Premarin every other day, potassium, and thyroid 0.3 mg daily.  Prior surgery includes an appendectomy, tubal ligation, cholecystectomy, and a fusion procedure on the right hand.  She has many allergies, including penicillin, sulfa, Keflex, iodine, IVP dyes, Betadine, aspirin, and nonsteroidal analgesics.

REVIEW OF SYSTEMS

Review of systems revealed a history of easy bruising but no bleeding.  No reactions to anesthetics.  Cardiopulmonary:  No shortness of breath, asthma, or angina.  Gastrointestinal Review:  Normal bowel habits.  Genitourinary:  No dysuria.

PHYSICAL FINDINGS

VITAL SIGNS:  Blood pressure 180/95, pulse 80 and regular.

EYES:  Recent eye examination showed best vision of 20/25 in the right eye and 20/80- in the left.  Pupils and extraocular motility and visual field by confrontation are normal.  Slit-lamp exam of the right eye showed a normal pseudophakia, and the left eye had a normal cornea and endothelium, and there was a dense nuclear and central posterior subcapsular cataract.  Intraocular pressure was 15 in the right eye and 17 in the left, and dilated fundus examination in each eye was normal.

EARS, NOSE, AND THROAT:  Tympanic membranes were normal.  The oral cavity showed dentures in place, and the pharynx had no lesions.

NECK:  The neck had normal carotids without bruits.

CHEST: Chest was clear to auscultation.

HEART:  Heart had a regular sinus rhythm without murmur.

PLAN

Plan is a cataract extraction with lens implant of the left eye under local anesthetic as an outpatient.  She understands the major risks, such as loss of the eye, and that an implant may not be done because of surgical problem.

FOOTNOTE

Line 26 (Page 1).  A zero was inserted before the decimal point for clarity.

Line 26 (Page 1).  The second reference to appendectomy was deleted.

Line 42 (Page 1).  Is was changed to are for subject-verb agreement.