Chief Complaints:
1. LS: Low Vision.

HPI:
History:
Eye Diagnosis _ presbyopia Cataracts, ho pituitary tumor followed at Jacobi hospital last vf 1/18.
LEE 5 years jgb.
NEE _, 1 year.
Referred by _self.
Ocular Symptoms _ no pain, BIRT no flashes or floaters.
Certified LB? _ NO.
Certified Legally Blind/Counselor _.

Medical History: Type 2 diabetes x 1980 diet controlled fbs 97 last week, Migraine, Obesity, Osteoarthritis, Thyroid removed x 2 years, Pituitary tumorx 2 years.

Family History:
no family history of eye disease.

Social History:
Tobacco Use:
Tobacco Use/Smoking
Are you a current smoker
Drugs/Alcohol:
Alcohol Screen
Points 1
Interpretation Negative

Medications: Taking Albuterol Sulfate HFA 108 (90 Base) MCG/ACT Aerosol Solution 2 puffs as needed Inhalation every 4 hrs, Taking Aspir-81 81 MG Tablet Delayed Release 1 tablet Orally Once a day, Taking Lisinopril 20 MG Tablet 1 tablet Orally Once a day, Taking Metoprolol Tartrate 25 MG Tablet 1 tablet Orally Twice a day, Taking Prilosec 20 MG Capsule Delayed Release 1 capsule Orally Once a day, Taking Simvastatin 20 MG Tablet 1 tablet in the evening Orally Once a day, Taking Cabergoline 0.5 MG Tablet 1 tablet Orally , Taking Levothyroxine Sodium 100 MCG Tablet 1 tablet on an empty stomach in the morning Orally Once a day, Medication List reviewed and reconciled with the patient

Allergies: N.K.D.A.

Objective:

Vision Examination:
Auto Refraction
Sph Cyl Axis Add DVA NVA
OD +2.00 -2.00 86
OS +1.75 -0.50 46

Spectacle
Presenting
Sph Cyl Axis H Prism V Prism Add DVA NVA PH
OD +2.25 -0.50 90 +2.50 20/40 20/30
OS +2.25 +2.50 20/40 20/30
OU 20/20 20/30

Final
Sph Cyl Axis H Prism V Prism Add DVA NVA PH
OD +2.25 -1.25 85 +3.00 20/30 20/30
OS +2.00 -0.50 80 +3.00 20/30 20/30
OU 20/30

Examination:
Ophthalmology:
PUPILS ___ PERRL(-)APD 4mm OU (both eyes).
EXTRAOCULAR MOVEMENT ___ full, smooth, commitant OU (both eyes).
COVER TEST ___.
CONFRONTATION VISUAL FIELD (CVF): ___ full to finger counting OU (both eyes).
AMSLER GRID ___.
LOW VISION SPECTACLES ___.
AOLITE SPECTACLES ___.
POWERMAG HAND MAGNIFIERS ___.
ESCHENBACH HAND MAGNIFIERS ___.
POWERMAG STAND MAGNIFIERS ___.
ESCHENBACH STAND MAGNIFIER ___.
TELESCOPES ___.
SUNWEAR EVAL ___.
CCTV ___.
LIGHTING ___.
HAND MAGNIFIERS _____.
STAND MAGNIFIERS ___.
COIL HAND MAGNIFIERS ___.
COIL STAND MAGNIFIERS ___.
ADNEXAE: ___ clear OU.
CORNEA: ___ clear OU.
CONJUNCTIVA: ___ clear OU.
IRIS: ___ clear OU.
ANGLES ___ D&Q OU 3×3 OU.
LENS: ___ nuclear sclerosis Grade 2 OU (both eyes).
VITREOUS: ___.
TBUT ___.
UNDILATED FUNDUS EXAM ____ CD ratio: 0.4/0.4 A/V 1/3 OU Macula: clear OU.
DILATED EYE EXAMINATION _____ one gtt 1%T,one gtt 2.5% PE CD ratio 0.4/0.4 OU A/V ratio 1/3 OU Macula sharp, distinct Peripheral retinal no tears, holes 360 degrees to extent seen OU.
INTRAOCULAR PRESSURE (IOP):
Right Eye 16
Left Eye 14
time 12.02

Assessment:

Assessment:
1. Presbyopia – H52.4 (Primary)
2. Age-related nuclear cataract of both eyes – H25.13
h/o pituitary tumor, being followed at Jacobi hospital every 6 months for VF.

Plan:

1. Age-related nuclear cataract of both eyes
Notes: Patient Educated with: Care of eye diseases.pdf (Care of eye diseases.pdf).

2. Others
Notes: order new bifocal rx thru metroplus, continue jacobi to monitor pit tumor, if no improvement with glasses consider cat xt.

Procedure Codes: 92015 REFRACTION, 92225 SPECIAL EYE EXAM, INITIAL

Preventive:
Screening/Special Tests:
CQM Exceptions
BMI not calculated Patient refused to record height/Weight
Immunizations:
Influenza
Have you had a flu shot since the most recent September 1? Yes

Follow Up: will call when devices or glasses arrive (Reason: dispense with optician)