Received Jun 10, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| VARZOS | ZOSTER (SHINGRIX) | GLAXOSMITHKLINE BIOLOGICALS | 1 | 334T3 | IM / RA |
Patient presents with flashes, floaters, dark spots in vision. Last saw Dr. 4/25/25 for similar concerns but was diagnosis with syneresis. States that flashes of light have improved since then but still noticing a handful of floaters. Received Shingrix vaccine in 4/18/25. When the patient spoke with his PCP, his PCP suggested seeing ophthalmology d/t concern for possible reaction from the vaccine. Reports mild pain worsened with EOM's. OS floater in central vision, and flashes superotemporal (12 times per day, fleeting) Past Ocular History - Wears glasses, no contacts - No prior surgery or laser - No prior trauma - High myope -7/-6 sphere
Hyperlipidemia, unspecified hyperlipidemia type - Long-term statin use since his 20s due to family history of high cholesterol - Last year's labs showed slightly elevated triglycerides
Hyperlipidemia, unspecified hyperlipidemia type - Long-term statin use since his 20s due to family history of high cholesterol - Last year's labs showed slightly elevated triglycerides
atorvaSTATin (LIPITOR) 40 MG tablet cetirizine (ZYRTEC) 10 MG tablet fluticasone propionate (FLONASE) 50 mcg/actuation nasal spray
NKDA
Past Medical History - Denies history of diabetes or hypertension 1983: Allergy Comment: grass, cats, dust No date: Hyperlipidemia Allergies Season allergies (takes Zyrtec and flonase) Social History - Denies tobacco, EtOH, illicit drugs Last edited by MD on 5/14/2025 3:05 PM. (History) ROS Positive for: Eyes Last edited by MD on 5/14/2025 2:09 PM. (History) Diagnoses Codes Comments Posterior vitreous detachment of left eye - Primary H43.812 Vitreous syneresis of right eye H43.391 Base Eye Exam Visual Acuity (Snellen - Linear) Right Left Dist cc 20/20 20/20 -1 Tonometry (Tonopen, 2:16 PM) Right Left Pressure 10 11 Pupils Dark Light Shape React APD Right 5 3 Round Brisk None Left 5 3 Round Brisk None Visual Fields Right Left Full Full Extraocular Movement Right Left Full, Ortho Full, Ortho Neuro/Psych Oriented x3: Yes Mood/Affect: Normal Dilation Both eyes: 1.0% Mydriacyl, 2.5% Neo Synephrine @ 2:17 PM Edited by: MD Edited by: MD Slit Lamp and Fundus Exam External Exam Right Left External Normal Normal Slit Lamp Exam Right Left Lids/Lashes Normal Normal Conjunctiva/Sclera White and quiet White and quiet Cornea Clear Clear Anterior Chamber Deep and quiet Deep and quiet Iris Round and reactive Round and reactive Lens Clear Clear Fundus Exam Right Left Posterior Vitreous Shafer negative, vitreous syneresis, no PVD Shafer negative, +PVD Disc PPA PPA C/D Ratio 0.2 0.2 Macula Normal Normal Vessels Normal Normal Periphery Normal Normal Edited by: MD Progress notes I did not examine this patient on this date of service. I have reviewed the resident's documentation and I agree with their findings and plan unless otherwise noted. MD Reviewed only non supervised MD at 05/14/25 2309 Author Type: Resident Status: Signed Assessment: Patient: PVD, left eye Vitreous syneresis of right eye - presents with flashes, floaters, dark spots in vision. Last saw Dr 4/25/25 for similar concerns but was diagnosis with syneresis. States that flashes of light have improved since then but still noticing a handful of floaters. OS floater in central vision, and flashes superotemporal (12 times per day, fleeting) - VA 20/20 both eyes, normal IOP, no APD - SLE unremarkable - DFE: OS: new PVD negative, no rt/rd Plan: - counseled patient about new PVD - RT/RD return precautions discussed Follow up: 6-8 weeks repeat DFE with Dr. ATTESTATION: I chose to manage this patient independent of direct staff supervision. I examined this patient in the Ophthalmology clinic. Attending doctor: Dr. MD Ophthalmology PGY-2 Resident Hospital