Chief Complaint & History of Present Illness :
cc: I have something in my eye
HPI: this is a 67 yo female who has the sensation that something is in her eye. It began gradually last night. It is more irritated if she opens her eye but light does not bother it. SHe denies any change in her baseline vision. She denies ha but had 15 seconds of pain lateral to her eye last night. She has a history of 3 eye surgeries. One was a cataract surgery.
Medical Decision Making (MDM) :
The patient’s irritation was relieved with proparicaine. Her visual acuity is diminished bilaterally but worse in the right eye. The patient does not perceive a change in her vision and I believe this may be her baseline. I do not see a FB, ulcer, dendritic lesion, fluorescene uptake or flare cells. The problem seems to be the external eye. Though I do see a pupillary defect this appears old
and the patient does not have photophobia and tells me she has had many surgeries in this eye. She most likely has a conjunctivitis.She will continue her visine drops. I would like her to fu with or her opthomologist 08/03/2018.
ED Diagnosis (Current Problem List) :
Problem Associated ICD-10-CM Code Status Onset
H57.8 – OTHER SPECIFIED DISORDERS OF EYE AND Active 2018
Sensation of irritation of eye proper
ADNEXA
Past Medical History :
PMH: seebelow
Historical Diagnoses (Full Problem List)
BENIGN ABDOMINAL TUMOR REMOVAL (Unknown date), Diabetes mellitus type 2 (Unknown date), Hepatitis C (Unknown
date), Hernia repair (Unknown date), Hypertension (Unknown date)
Allergies
No Known Allergies
Home Medications
Acetaminophen, milligram
amLODIPine, 10 milligram orally every day
Aspirin, 81 milligram orally every day
Bactrim DS,
Benazepril, 40 milligrams orally every morning
benazepril, 20 milligram orally every evening
Gabapentin, 100 milligram orally every 8 hours (Duration: 10 days)
HYDROcodone-acetaminophen 5 mg-325 mg, 1 tablet orally every 6 hours PRN pain, Start Date: 05/12/2017
Imipramine, 25 milligram orally every day at bedtime
Insulin NPH-Regular Human Rec 100 unit/mL (70-30), 30 units subcutaneously every evening
Metformin, 1000 milligrams orally every morning
metFORMIN, 500 milligram orally every evening
Metoprolol (Succinate) 24 hr Tab, 100 milligrams orally every day
NovoLOG Mix 100 unit/mL (70-30), 32 unit subcutaneously 2 times per day
Simvastatin, 20 milligram orally every evening
Thiamine, unk intramuscularly every month
traMADol, 25 milligram orally every 8 hours PRN pain(Duration: 14 days)
Immunizations
Influenza, seasonal, injectable – 141 (2016), Tdap – 115 (2017)
Social History
Tobacco Use
Never smoker
Alcohol Use
None Reported : ALCOHOL HISTORY Last Documented By: SHASHI RAGHWAN, RN on 01/25/2017 16:00
Recreational Drug Use
None Reported : RECREATIONAL DRUG HISTORY Last Documented By: SHASHI RAGHWAN, RN on 01/25/2017 15:32
Review Of Systems
ROS:
IX Not indicated for Chief Complaint
Vital Signs
Most Recent Set of Vitals:
BP: 155/98 08/02/2018 21:13
Pulse: 102 08/02/2018 21:13
Temp: 36.4 C 08/02/2018 21:13
Resp: 18 08/02/2018 21:13
02 Sat: 97%(Room Air) 08/02/2018 21:19
Calculated BMI: 42.9 08/02/2018 21:13
Vitals: Pulse Ox
02 Source : 02 Delivery : 02 L/min FiO2 %
Pulse Ox Reading: 97 % Interpretation: Normal Date/Time:
Physical Exam
GENERAL
wdwnf no acute distress
EYES
Right eye: very slight injection to right lateral sclera. + pupillary defect /irregularity in upper left quadrant of the iris.
Slight diminished pupillary constriction.
Slit lamp: no FB, &corneal abrasion, dendritic lesion, ulcer or fluorescene uptake. No flare cells, no puss or blood in anterior chamber. normal exam.
Os 20/50 od 20/70. Patient feels her vision is baseline.
Sensation of FB completely relieved with proparicaine.
NECK
supple
RESP
non labored
EXTREMITIES
NEURO
Higher functions
nl gait, nl speech
ED Diagnosis (Current Problem List) :
Problem Associated ICD-10-CM Code Status Onset
Sensation of irritation of eye proper
H57.8 – OTHER SPECIFIED DISORDERS OF EYE AND Active 2018
ADNEXA
Disposition
Disposition Decision Date/Time:
VC from ED to: home
Condition at D/C: stable and improved.
CPT code :99282
ICD 10: H579
