HISTORY
Patient is a 74-year-old male who has bilateral
cataracts. He wants to get them fixed to
improve his vision. He states even with
his glasses on or off, he sees better and he is hoping when he gets his
cataracts done, he could see a lot better.
He is normally in very good health.
ALLERGIES
He has no known allergies.
PAST MEDICAL HISTORY
1. He has
early-onset dementia of the Alzheimer type for which he takes Aricept 10
milligrams and he has actually been stabilized over the last year. If nothing else, he might have some slight
improvement per his wife.
2. Status
post prostate cancer. His PSA has been 0
per Dr. Turnbull. He had a radical
prostatectomy and this will be followed with myself in the next 5 months.
3. His other
problem is he has overflow incontinence and this will be addressed.
4. Past
medical history otherwise, he has had bilateral knee replacement. He has prostate cancer removed.
FAMILY HISTORY
Significant for mother died at 53 of stomach cancer. Father died of electrocution in his 30s. He is an only child.
SOCIAL HISTORY
Does not smoke, does not drink. He has worked hard all his life. He still stays very active.
PHYSICAL EXAMINATION
VITAL SIGNS: His
blood pressure is 160/78, his pulse is 72 and regular.
ENT EXAM: Bilateral
cataracts noted. There are no carotid
bruits. Tympanic membranes are clear.
CHEST: He has
bilateral breath sounds. Clear to
auscultation.
CARDIAC EXAM: Revealed
a regular rate and rhythm without ectopy.
He has a soft 1/6 murmur.
ABDOMEN: Soft.
EXTREMITIES: No
edema.
LABORATORY DATA
He has a normal EKG which shows a normal sinus rhythm. Normal voltage changes. His CBC showed a white count of 6.3, H and H
14.5 and 43.4. His panel-7 was all
within normal limits including a panel of potassium of 4.9 and glucose 113;
this was nonfasting.
ASSESSMENT
1. Bilateral
cataracts. He is going to undergo
cataract repair of the eye on 17th and and they are going to go back to do the
next one whenever he recuperates from the first one. He is cleared from a surgical standpoint and
medical standpoint.
2. Dementia
of Alzheimer type ______.
3. Status
post prostate cancer, stable.
PLAN
Patient is cleared for cataract surgery in my opinion. Risks and benefits have been discussed with
Dr. Friman.
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