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Ophthalmology History and Physical Transcription Sample

CHIEF COMPLAINT:  Double vision after left eye socket fracture.

HISTORY OF PRESENT ILLNESS:  This (XX)-year-old male was noticed to have persistent nonimproving diplopia after suffering fractures of the left eye socket. The patient reports that a foot hit the left side of his eye socket wall while playing. The patient noted immediate swelling that has improved. There was diplopia that improved slightly; however, there has been no improvement over the last 4 days. The patient had nausea and dizziness from this problem, but this has improved as well. There is pain with down gaze and right gaze as well. The patient reports that the eye remains in a higher position, though there is no change in the position of the eye ball. There is numbness of the left side of the face that has not improved as well and associated drooping of the left upper eyelid. The patient was evaluated by the ophthalmologist, who noted orbital fractures on the left side. A CT scan of the orbit was obtained confirming medial and inferior orbital fractures of left eye.

PAST MEDICAL HISTORY:  Significant for asthma.

1.  Acetaminophen.
2.  A 5-day course of cephalexin.
3.  Afrin nasal spray used p.r.n.
4.  Albuterol inhaler used on a p.r.n. basis.

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

SOCIAL HISTORY:  The patient is employed. Smoked 4 cigarettes per day over the last 12 years. Does not use alcoholic beverages. The patient has previously lived outside of the country for a period of time.

FAMILY HISTORY:  Significant for diabetes mellitus, cancer and heart disease.

ALLERGIES:  The patient reported no known drug allergies.

PHYSICAL EXAMINATION:  Ophthalmic examination showed a corrected visual acuity measured at 20/30, both eyes. Extraocular muscle ductions were intact on the right side and decreased to 40% infraduction on the left side with 100% lateral and medial and superior ductions noted. Confrontation visual fields were intact to finger counting stimuli in both eyes. External exam showed 1 to 2+ edema and ecchymosis of the left periorbital region with 2+ dense hypesthesia in the area of the left infraorbital nerve with no step-off noted and no orbital emphysema palpated with orbital rim palpation. There were exophthalmometer measurements with a base of 97 utilizing the Hertel unit measuring 13 mm on both sides. Retropulsion was 1+ resistance on the left side and normal on the right side.

Slit-lamp examination was within normal limits on the right side. There was 2+ mechanical ptosis of the left upper eyelid present with 1+ lash ptosis. Normal lacrimal puncta, conjunctivae and sclerae, iris shape and morphology. Anterior chamber depth is 3+ with no cell or flare and the lens was clear on both sides.

Sensorimotor testing documented a 10 prism diopter left hypertrophia that was increasing on increasing down gaze.

A CT scan of the orbits performed was reviewed. This documented a left intraorbital wall fracture that was at the mid orbit level with entrapment of the perimuscular left inferior rectus, with a smaller fracture of the left medial orbital wall present.

Multiseries visual external ocular photography documented primary left hypertrophia with poor infraduction on the left side.

IMPRESSION:  Acute left orbital floor and medial orbital wall fractures, left eye. This is seen with nonimproving diplopia and inferior rectus perimuscular entrapment. There is dense hypesthesia in the distribution of the left infraorbital nerve with persistent pain.

PLAN:  Planned procedure is for left orbital floor and medial orbital wall repair utilizing nylon orbital implant, left side. 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. The procedure was diagramed on an anatomical chart in the presence of the patient and all questions were answered. The patient is aware that the dense hypesthesia in the distribution of the left infraorbital nerve will take up to a year for improvement and may result in no improvement. The patient is further aware that direct neuromuscular damage to the muscle and/or nerve would result in persistent diplopia even after orbital fracture repair that would require extraocular muscle surgery at a later time. The patient was advised to restrict blowing his nose for 2 weeks after surgery.