additional diagnostic studies would H e a l t h M e d i c a l
A 79-year-old male remarks on his first visit that he has noticed a
gradual decrease in vision in both his eyes since last year. His old
medical record has not yet arrived at your office. He states that since
he moved from Florida a year ago, he has not had an eye examination and
does not yet know an ophthalmologist. He is having difficulty carrying
on his activities of daily living that involve his sight. He states that
he cannot recognize people at some distance until they come quite close
and he is often frightened by his perception of strangers speaking to
him. Watching television and reading are becoming increasingly difficult
for him. He states that glare is a problem and notes that a few times
he almost tripped over something on the floor. He still drives his car
in the local community. He asks if you think he may have a cataract. He
says his wife had two cataracts in the past and he remembers her
complaining of vision problems which have now resolved.
Vital Signs: BP 128/84; HR 82; RR 18; BMI 24.
Chief Complaint: Decrease in my vision; glare is very bothersome!
Discuss the following:
1) What additional subjective data are you seeking to include past medical history, social, and relevant family history?
2) What additional objective data will you be assessing for?
3) What are the differential diagnoses that you are considering?
4) What laboratory tests will help you rule out some of the differential diagnoses?
5) What radiological examinations or additional diagnostic studies would you order?
6) What treatment and specific information about the prescription that you will give this patient?
7) What are the potential complications from the treatment ordered?
8) What additional laboratory tests might you consider ordering?
9) What additional patient teaching may be needed?
10) Will you be looking for a consult?
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