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OPHTHALMOLOGY CARE CENTER 6481 SIGHT BOULEVARD ANYTOWN, FL…
OPHTHALMOLOGY CARE CENTER
6481 SIGHT BOULEVARD ANYTOWN, FL 32719 407-555-5137
PATIENT: HAMMOND, DARLENE
ACCOUNT/EHR #: HAMMDA001
DATE: 10/17/18
Attending Physician: Walter P. Henricks, MD
CHIEF COMPLAINT: Chronic, stable mildly diminished vision
HISTORY OF PRESENT ILLNESS: This 47-year-old female with the presumptive diagnosis of cone dystrophy was referred to us for further evaluation of chronic mildly diminished visual acuity and dyschromatopsia by her optometrist, Dr. Wassau. The patient reported that her vision has never been correctable to 20/20. The best visual acuity she remembers having is 20/30 in the left eye.
PAST EYE HISTORY: She was diagnosed with amblyopia in the right eye as a child and underwent a trial of patching at age 10. She is anisometropic, and her vision has always been worse in the right eye, presumably due to amblyopia.
PAST MEDICAL HISTORY: None
MEDICATIONS: She takes no medications on a regular basis. She has never taken hydroxychloroquine or antipsychotic medications.
FAMILY HISTORY: She has several family members with mildly subnormal vision. Her mother, brother, sister, and son all have mildly reduced vision, in the range of 20/30 to 20/50. All of the affected family members are able to drive.
SOCIAL HISTORY: She works as a clerk. Her social history is otherwise unremarkable.
OCULAR EXAM:
Visual acuity (with corrective lenses): Right eye20/70; left eye20/40
Current spectacle correction: Right eye: 20.75 12.50 3 037; left eye: 23.00 sphere
Manifest refraction (MRx) improves the acuity of the right eye to 20/60, while the left eye remains unchanged.
Motility: Orthophoric (normally aligned) in primary gaze; versions full
Intraocular pressure: Right eye12 mmHg; left eye14 mmHg
Pupils: Normal in both eyes. No relative afferent pupillary defect.
External and anterior segment examination: Normal in both eyes
Dilated fundus exam: There was optic disc pallor, predominantly temporal, in both eyes. Peripapillary atrophy and grey temporal crescent were noted in the left eye. The macula, vessels, and periphery were normal in both eyes.
Ishihara plates: 2/14 OD, 3/14 OS
Nagel anomaloscope: Protanomalous match
Goldmann Visual Field testing: Right eyebaring of blind spot with mildly constricted I2e isopter; left eyeconstricted I2e isopter
Electroretinogram (ERG): Scotopic bright flash 589 microvolts in the right eye, 572 microvolts left eye; scotopic dim flash 405 microvolts right eye, 340 microvolts left eye; photopic bright flash 180 microvolts right eye, 185 microvolts left eye
DX: Autosomal dominant optic atrophy, or dominant optic atrophy (DOA)
TREATMENT: A blood sample for molecular studies was obtained. The clinical and genetic features of autosomal dominant optic atrophy were discussed. More information will follow when results of the genetic testing are complete. The patient returned to the care of her local eye doctor.
Walter P. Henricks, MD
WPH/mg D: 10/17/18 09:50:16 T: 10/19/18 12:55:01
What are the 3 CPT codes and the 1 ICD10CM code?
