Established patient returns to the eye clinic for complete diabetic eye eval CC: Patient reports no visual or ocular complaints OU. Denies: flashes, floaters, diplopia, HAs, watering, itching, dryness. Ocular Medications: none Diabetic Review - Year diagnosed: ~2009 - Management: oral medication - Blood sugar range per patient: does not check - Most recent HA1c: Nov 15, 2016 - 7.9 H% The patient was last seen 06/07/2016 with Dr. Stronz for complete eye eval The patient is being followed for: 1. Diabetes without retinopathy OU; no macular edema OU 2. Hypertension without retinopathy OU 3. Nuclear sclerotic and cortical cataracts OU 4. Hyperopia with presbyopia OU REVIEW OF SYSTEMS [-]Constitutional [-]ENT [+]Cardiovascular: Coronary artery disease, Hypertension, Paroxysmal atrial fibrillation; s/p MI x1 x~2013 [+]Respiratory: COPD [+]Gastrointestinal: GERD [-]Genitourinary [-]Musculoskeletal [-]Integumentary [+]Neurologic: Peripheral neuropathy [-]Psychiatric [+]Endocrine: DM Type 2 [+]Hematologic/Lymphatic: Hypokalemia, ASA 81mg [-]Autoimmune/Allergic PAST OCULAR HX: [-]Trauma: [-]Surgery: [-]Strabismus: [-]Other: FAM. OC HX: [-]Glaucoma [-]Macular Degeneration [-]Blindness [-]Retinal Detachment Other: PSHX: [+]Tobacco: ~1/2-1 PPD [+]ETOH: 3 beers/day Current Medications Reviewed Allergies - MEDROL, CEPHALEXIN, LOVASTATIN, BENADRYL, SIMVASTATIN, ROSUVASTATIN ORIENTATION: Time/Person/Place - appropriate x3 MOOD AND AFFECT: Appropriate CURRENT SPECTACLE RX: OD: +2.25 sphere OS: +2.00 -0.25 x 040 ADD: +2.50 OU VISUAL ACUITY: With Correction DIST OD 20/20 OS 20/20 EOM: Smooth and full w/o Diplopia/Pain Hirschberg Alignment: no apparent tropia OD/OS CONFRONTATION VIS FIELDS: FULL TO FINGER COUNTING OU PUPILS: PERRL: Yes; (-)APD REFRACTION AND BEST VISUAL ACUITY: OD: +2.25 sphere 20/20 OS: +2.00 -0.25 x 040 20/20 ADD: +2.50 OU VA to provide the following: [+]Line bifocal [+]UV400 [+]Scratch coating [+]Tint at patient's preference SLIT LAMP EXAM: Ocular Adnexa: Clear OU Lids/Lashes: Clear OU Sclera/Conjunctiva: Clear and quiet OU Cornea: (Epithelium, Stroma, Endothelium, Tear film): arcus OU, Tbut: 0 sec OU, poor tear film stability OU. Anterior Chamber: Deep and quiet OU; no cells or flare OU Iris: Flat and intact OU; no rubeosis OU TONOMETRY: OD: 11 mmHg OS: 11 mmHg TIME: 0920 DILATION: 1 GTT Tropicamide (1.0%) OU 1 GTT Phenylephrine (2.5%) OU INTERNAL (78/90, 20D BIO): LENS: (anterior/posterior capsule, cortex, nucleus) OD: G1 cortical, G2 NS OS: G1 cortical, G2 NS VITREOUS: OD: syneresis OS: syneresis NERVE: (-) NVD OU OD: 0.15/0.15 cup/disc ratio (horiz/vert) Normal Color/Margins OS: 0.20/0.20 cup/disc ratio (horiz/vert) Normal Color/Margins MACULA: (-) clinically significant macular edema OU OD: Flat and intact; no blood, fluid or exudates OS: Flat and intact; no blood, fluid or exudates BLOOD VESSELS: (-) NVE OU OD: tortuosity and crossing changes OS: tortuosity and crossing changes; 2 sclerosed vessels inferior arcades with several hemorrhages PERIPHERY: OD: No holes, tears or detachments OS: No holes, tears or detachments ADDITIONAL TESTS: (+) OCT: Macular Thickness Report Sig Strength Avg Central Thickness OD: 8/10 - 277um; good foveal contour, (-) tears/holes/detachments, all quadrants WNL (green) OS: 8/10 - 249um; good foveal contour, (-)tears/holes/ detachments, inferior thinning/atrophy -Impression: OD: WNL, stable to baseline 12/2013 OS: atrophy inferior nasal to macula - new, not seen on baesline 12/2013 or previously notated (+) Fundus retinal photos taken and reviewed OU OD: Fundus and cupping as described above OS: Fundus and cupping as described above -Impression: OD: stable to baseline photos 11/2008 and previous 05/2016 OS: new BRVO not previously seen in baseline photos 11/2008 or previous 05/2016 (+) BLOOD PRESSURE Right arm, sitting @ 1021: 129/72, Pulse: 68 ASSESSMENT: 1. Branched retinal vein occlusion OS without macular edema; new - patient said he noticed cloud across vision OS sometimes for past month - BP today: 129/72 - patient currently taking aspirin daily 2. Diabetes without retinopathy OU; no macular edema OU; stable 3. Hypertension with mild angiopathy OU; stable 4. Mild mixed cataracts OU; stable 5. Refractive error with presbyopia OU; stable PLAN: 1. Educated patient on today's findings. Discussed importance of continued follow up care and testing to ensure no further progression. Patient voiced understanding. Ordered carotid ultrasound and blood work (CBC with differential, CRP, ESR, HgA1C, lipid panel and glucose). Advised patient to call 911 or go to the emergency room ASAP if any sudden painless transient monocular loss of vision, jaw pain, temple/scalp pain, sudden muscle weakness or confusion. Monitor 2 months with VF/Gonio/DFE 2. Patient educated on findings, benefits of tight glucose control, modifiable risk factors, and the importance of continued follow with primary care physician; monitor at complete exam 3. Educated patient on todays findings. Discussed importance of good blood pressure control and continued management with primary care team. Monitor complete. 4. Educated patient; surgery not indicated; monitor complete exam 5. New spec Rx issued today. Monitor complete RTC: 09/2017 VF/gonio/DFE 07/2018 Complete/OCT/Photos