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Ophthalmology History and Physical Medical Transcription Sample Report

DATE OF ADMISSION:  MM/DD/YYYY

CHIEF COMPLAINT/REASON FOR ADMISSION:  Blocked vision from upper lid drooping.

HISTORY OF PRESENT ILLNESS:  This (XX)-year-old gentleman notes obstruction of vision from downward sagging of both upper eyelids. This causes impairment when driving. He believes that this is dangerous. He has had some near accidents. The patient reports that by stretching his eyebrow upward, he is able to see more clearly. He presented first to his primary care physician, who recommended ophthalmological evaluation. His ophthalmologist then requested oculoplasty consultation. There was no history of myasthenia gravis or other neuromuscular disease. The level of the eyelid does not change during the day and there is no associated diplopia. He further reports that he has had injuries in which he has bumped his head because he was not able to see clearly his superior visual fields.

PAST MEDICAL/SURGICAL HISTORY:  Significant for early cataract formation, status post tumor removed from chest, hypercholesterolemia, gastroesophageal reflux disease, hypertension, history of seasonal allergy secondary to dry eye, history of asthma, history of diverticulitis, and hypertension.

MEDICATIONS:  Included Nexium, Advair, simvastatin, albuterol, multivitamin, Ginkgo biloba and saw palmetto. The patient denied taking aspirin or other anticoagulants.

REVIEW OF SYSTEMS:  A 14-point comprehensive review of system is otherwise negative.

SOCIAL HISTORY:  The patient is employed. He does not use tobacco products. He has an occasional alcohol beverage. He exercises by golfing thrice weekly.

FAMILY HISTORY:  Significant for diabetes mellitus, carcinoma, tuberculosis, heart disease, hypertension, and kidney disease.

ALLERGIES:  REPORTED NO KNOWN DRUG ALLERGIES.

OPHTHALMIC EXAMINATION:  Showed a corrected visual acuity measured at 20/50 in right eye and 20/30 in left eye.  With eyelid lift, the patient reported improvement of vision on both sides. Pupils are normal on both sides. Extraocular muscle ductions were intact with no diplopia reported. Confrontation visual fields were 2+ depressed superiorly on the right, and 2 to 3+ depressed superiorly on the left side.  With eyelid lift, this improved the superior restriction bilaterally.  External examination showed 5 mm of eyebrow ptosis on the right side and 6 mm eyebrow ptosis on the left side. There was 1 to 2+ compensatory occipitofrontalis muscle contracture elevating the upper eyelid excessive dermatochalasis and steatoblepharon on both sides, which was graded at 2+ in both eyes. The patient was 2 to 3 Fitzpatrick skin type with 1+ upward Bell phenomenon and a negative ice test for myasthenia gravis for 5 minutes. Basal tear secretion test measured 12 mm wetting on the right, 13 mm wetting on the left side. There was no fatigue on sustained upgaze and no lagophthalmos. The eyelid margin to corneal reflex distance was 0.0 mm in right eye and -1.0 mm in left eye. Vertical palpebral aperture measured 5 mm in right eye and 4.5 mm in left eye.  Levator function was 14 mm in right eye and 15 mm in left eye. The eyelid margin increased to 6 mm in right eye and 5 mm in left eye.

Hand-held slit-lamp examination showed 50% obstruction of the superior pupillary aperture by the upper eyelid excessive tissue and ptosis on the right, and 60% obstruction on the left side by the same phenomenon. There was positive Herring phenomenon further depressing the left upper eyelid when the right upper eyelid was elevated into the appropriate position. There was 2+ lateral entropion formed from the excessive upper eyelid dermatochalasis resting on the superior lash margin and inducing 2+ eyelash ptosis. Lacrimal puncta appeared normal. Conjunctivae and sclerae were normal, iris shape and morphology was normal. The cornea had an adequate tear film height with normal epithelium, stroma and endothelium in both eyes, and anterior chamber depth was 3+ with no cell or flare. The lens showed 1+ anterior cortical and nuclear sclerotic and posterior cortical changes on both sides. Multi series digital external ocular photography documented left greater than right upper eyelid blepharoptosis associated with upper eyelid excessive dermatochalasis and steatoblepharon resting on the superior lash margin, causing obstruction of the superior pupillary aperture despite activation of compensatory occipitofrontalis muscle contracture on both sides. A full-field 246 point screening visual field test performed was reviewed. This documented superior depression to within 4 degrees of the superior pupillary aperture to within 4 degrees of the central visual field on the right side and within 12 degrees of the central visual field on the left side. With upper eyelid elevation retesting, this improved the superior visual field to 52 degrees superiorly on the right side and 43 degrees superiorly on the left side.

IMPRESSION:  Involutional left greater than right upper eyelid levator palpebrae superioris aponeurotic dehiscence and blepharoptosis in both eyes.  This was seen together with involutional and actinic-related upper eyelid excessive dermatochalasis and steatoblepharon with formation of lateral entropion in both eyes.

RECOMMENDATION AND PLAN:  Planned procedure is for bilateral external levator palpebrae superioris aponeurotic resection, upper eyelid, both eyes. This will be combined with bilateral upper eyelid blepharoplasty with correction of lateral entropion in both eyes. I have discussed the risks, benefits, and alternatives to surgery including no surgical intervention. The patient is aware of the risk of bleeding, infection, loss of vision, scarring, asymmetry, eyelid hypesthesia, problems with anesthesia, dry eye formation after surgery, failure of the procedure, as well as a need for revision surgery. All questions were answered. The patient is aware that, after this episode of consultative care, he will return to his regular eye care professionals for ongoing needs.

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