Leishay Julian

Write-up for Eyes

Date: 2/21/2014

Time: 1200

Biographical: D.T, 42, Female, African American, D.O.B 12-4-1971, Student, referred by Dr. Thompson, Oriented to person, time, place, reliable source of information
History of Present Illness - Chief Complaint: Difficulty with vision bilaterally

Symptom Analysis: Difficultly with vision bilaterally

1. Where: States difficult vision in eyes bilaterally. Denies symptoms of increased pain patterns.. States symptoms first noted at school on 5/20//2002. 2. When: The symptoms occurred the afternoon of 5/20/2002. Symptoms developed gradually and have worsened since onset. States “my vision has remained poor, but stabilized since 2009.” Denies specific time or day of week correlated to symptoms. 3. What: Experiences blurry vision when viewing distant objects. Denies any specific event in relation to symptoms. States use of prescription lenses correct vision difficulty. Denies any aggravating factors. States symptoms as “an annoyance”. Denies any strenuous daily activities that contribute to blurry vision. 4. How: States “nearsightedness is likely due to genetics”. Denies any additional factors or stressors occurring at work, school, or home. States nearsightedness present in father and mother. Reports similar episodes occurred in the in the past. 5. Why: Suspects nearsightedness is likely due to genetics. Denies other symptoms occurring at same time. Denies any major changes in environment, school, home, or work. States corrective lenses have corrected nearsightedness.

A. Difficulty with Vision * States difficulty with vision in both eyes, primarily central, sustained, nearsighted vision bilaterally, corrected by lenses. Denies history of cataracts. Denies history of inadequacy of color vision. Denies presence of halos around lights, floaters, or diplopia. B. Eyelids * Denies recurrent hordeola, ptosis of the lids that interfere with vision bilaterally, growths or masses, itching. C. Pain * Denies burning, itching or nonspecific uncomfortable or gritty sensation. D. Secretions * Denies clear or yellow color, watery or purulent consistency, duration of tears that run down the face, decreased formation with sensation of gritty eyes, presence of conjunctival redness.

E. Medications * States use of 40mg Adderall XR PO daily, 50mvg Fluticasone Propinate nasal spray daily, Equate multivitamin PO daily. Denies use of antibiotics, eye drops or ointments, mydriatics, artificial tears. Denies use of glaucoma medications, other antioxidant vitamins, steroids, other prescription drugs, nonprescription drugs, complementary or alternative therapy.

Past Medical History

A. Denies trauma to the eye as a whole or a specific structure. Denies any events leading to trauma which resulted in efforts for correction B. Denies history of condition requiring eye surgery, laser corrective vision C. Denies history of chronic illness effecting the eyes or vision: glaucoma, diabetes, atherosclerotic cardiovascular disease, hypertension, thyroid dysfunction, collagen vascular diseases, HIV, inflammatory bowel diseases D. Denies use of steroids, Plaquenil, antihistamines, antidepressants, antipsychotics, antiarrhytmics, beta blockers

Family Health History

A. Denies retinoblastoma or cancer of the retina B. Denies color blindness, cataract formation, retinal detachment, retinitis pigmentosa, or allergies affecting the eyes C. States mother and father nearsightedness. Denies farsightedness, strabismus, amblyopia

Social History

A. Denies employment exposure to irritating gases, chemicals, foreign bodies, or high-speed machinery B. States participation in kendo which may endanger the eye C. States use of a protective headgear covering the eyes during kendo D. States use of corrective lenses last changed 6/04/11, glasses worn daily, adequacy of corrective vision -2.50; stores inside case at night, cleans with Windex dilution 1-2 times a week; last eye examination 6/09/13 E. Denies history of cigarette smoking

Risk Factors for Cataract Formation

* Denies steroid medication use * Denies exposure to ultraviolet light * Denies cigarette smoking * Denies history of diabetes mellitus * Denies current age a risk

Physical Assessment Findings

* Snellen A. (20/15) in each eye with corrective lenses B. Unable to identify chart in each eye without corrective lenses * Eyebrows A. Evenly distributed B. Symmetrical C. Blonde D. No lesions noted * Eyelids A. Symmetrical B. Eyelashes are thick C. Symmetrical blinking present D. No lesions noted E. No ptosis noted * Orbit A. No edema B. No pain C. No lesions noted * Lacrimal Puncta A. No swelling B. Do discharge C. No enlargement D. No redness E. No tearing noted * Conjunctiva A. Light pink B. No cobblestone appearance C. No swelling D. No exudate E. No foreign bodies F. Smooth * Sclera A. Moist B. Shiny without discharge * Iris A. Green bilaterally * Peripheral Test: visual fields A. Right side: 90 degrees B. Left side: 85 degrees * EOM (Extra Ocular Movement) A. No nystagmus noted * Convergence A. Bilateral symmetry * PERRLA A. Pupils equal bilaterally (4mm) B. Pupils round bilaterally C. Pupils respond to light symmetrically (4mm-2mm) D. Accommodation noted * Corneal Light Reflex A. Light reflex noted * Red reflex A. Red reflex noted bilaterally