Week 5 Assignment - MEDICAL RECORD 1 University Hospital...

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MEDICAL RECORD 1 University Hospital and Medical Center 4700 North Main Street Wellness, Arizona 54321 (987) 555-3210 PATIENT NAME: William Graves CASE NUMBER: 20066-OPH DATE OF BIRTH: 06/27/xx DATE: 04/05/xx PROGRESS NOTE SUBJECTIVE: Mr. Graves is a 66-year-old white man here today for his annual ophthalmology examination. He has no current complaints. He has a family history of glaucoma in his brother. He has a history of hypertension and type 2 diabetes mellitus. A pterygium was removed from his right eye 5 years ago. Pterygium (pronounced tur-IJ-ee-um) is a common eye condition that affects people who spend a lot of time outdoors. Because it often affects surfers, it is also known as surfer's eye. CURRENT MEDICATIONS: Glyburide 5 mg bid and Lopressor 50 mg bid. ALLERGIES: None OBJECTIVE Visual Acuities: Aided: OD 2/25-2 OS 20/30-1 OU 20/25 Unaided: OD 20/100 OS 20/80-1 OU 20/80 Externals: 2-mm Blepharoptosis OD. PERLA. EOMI. Blepharoptosis is abnormal low-lying upper eyelid margin with the eye in primary gaze. Normally, upper lid covers 1.5 mm of the superior part of the cornea.
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