AI Scribe for Ophthalmologists

OPHTHALMOLOGY — DIABETIC EYE EXAM, CATARACT EVAL FOLLOW-UP
Date: April 28, 2026   Provider: Dr. A. Okonkwo, MD — Ophthalmology
Patient: 67-year-old male   MRN: 70014

CHIEF COMPLAINT:
"My vision in the right eye has been getting hazier over the last 6 months and I have trouble with night driving."

HISTORY OF PRESENT ILLNESS:
67M with a 14-year history of type 2 diabetes (last A1c 7.8%, March 2026) and hypertension presents for annual dilated eye exam and cataract evaluation. Reports gradual painless decrease in vision OD over 6 months, worse with oncoming headlights at night. No flashes, floaters, scotomas, diplopia, or pain. No prior eye surgery. Last exam 12 months ago — early bilateral nuclear sclerosis noted, mild NPDR OU.

PAST OCULAR HISTORY:
Bilateral nuclear sclerotic cataracts (mild, last visit). Mild non-proliferative diabetic retinopathy OU, no macular edema. No glaucoma. No prior intraocular surgery, no laser treatment.

PAST MEDICAL HISTORY:
Type 2 diabetes mellitus x 14 years. Hypertension. Hyperlipidemia.
Medications: metformin 1000 mg BID, empagliflozin 10 mg daily, lisinopril 20 mg daily, atorvastatin 40 mg qHS, aspirin 81 mg daily.
Allergies: NKDA.

FAMILY HISTORY: Mother — primary open-angle glaucoma.
SOCIAL: Former smoker, quit 12 years ago, 18 pack-years total. No alcohol.

VISUAL ACUITY (uncorrected / corrected / pinhole):
                 OD                OS
Distance:        20/60 / 20/40 / 20/30   20/40 / 20/25 / 20/25
Near (corrected):  J5                       J3

MANIFEST REFRACTION:
OD: -1.25 -1.00 x 085 → 20/40
OS: -0.75 -0.75 x 095 → 20/25
Add: +2.50 OU

IOP (Goldmann applanation, 2:40 PM):
OD 16 mmHg   OS 17 mmHg
CCT: OD 542 µm, OS 545 µm

PUPILS: 4 mm round, briskly reactive OU. No RAPD.
EOM: Full OU. No diplopia.
CONFRONTATION VF: Full to count fingers OU.
EXTERNAL/LIDS: Mild dermatochalasis OU, no ptosis.

SLIT LAMP EXAMINATION:
                  OD                                OS
Lids/Lashes:      MGD trace                         MGD trace
Conjunctiva:      White and quiet                   White and quiet
Cornea:           Clear, no edema, no NV            Clear, no edema, no NV
AC:               Deep and quiet, no cell/flare     Deep and quiet, no cell/flare
Iris:             Round, reactive                   Round, reactive
Lens:             NS 2+ with posterior cortical     NS 1+
                  spokes 360° — visually significant

DILATED FUNDUS EXAM (1% tropicamide + 2.5% phenylephrine OU):
                  OD                                OS
Disc:             Pink, sharp, C/D 0.40             Pink, sharp, C/D 0.40
Macula:           Few microaneurysms temporal,      Rare microaneurysm temporal,
                  no edema, no exudate              no edema, no exudate
Vessels:          Mild AV nicking                   Mild AV nicking
Periphery:        Few dot-blot hemorrhages          Rare dot-blot hemorrhage
                  inferior arcade, no NVE           no NVE, no NVD

OCT MACULA (Cirrus, today):
OD CMT 268 µm, no intraretinal or subretinal fluid, normal foveal contour.
OS CMT 254 µm, no fluid, normal foveal contour.

PRIOR OCT (Sept 2025): OD 261 µm, OS 252 µm — stable.

ASSESSMENT:
1. Visually significant nuclear sclerotic cataract OD with posterior cortical spokes — symptomatic, BCVA 20/40 with glare, affecting night driving.
   ICD-10: H25.11 (right eye).
2. Early nuclear sclerosis OS, not yet visually significant. ICD-10: H25.12.
3. Mild NPDR OU without macular edema, stable from 2025. ICD-10: E11.3211 (right eye), E11.3212 (left eye).
4. Type 2 diabetes mellitus, not optimally controlled (A1c 7.8%) — discuss with PCP.
5. Hypertension — well controlled on lisinopril.

PLAN:
1. Cataract surgery OD — phacoemulsification with IOL (CPT 66984). Reviewed risks, benefits, alternatives, including endophthalmitis (~1/2000), cystoid macular edema, retinal detachment, posterior capsular tear with vitreous loss, refractive surprise. Patient consents, prefers monofocal targeting plano OD with reading glasses.
2. Biometry today: AL OD 24.18 mm, K1 43.50 / K2 44.25, ACD 3.21 mm. SRK/T and Barrett Universal II calculations: 21.0 D IOL targeting –0.18 D OD.
3. Pre-op clearance with PCP (BP, A1c, anesthesia eval). Surgery scheduling: 4 weeks.
4. Pre-op drops starting 3 days before surgery: moxifloxacin 0.5% qid OD, ketorolac 0.5% qid OD.
5. Post-op drops: prednisolone acetate 1% q2h day 1 then qid x 1 week, taper over 4 weeks; moxifloxacin 0.5% qid x 1 week; ketorolac 0.5% qid x 4 weeks. Latanoprost qHS not indicated — no glaucoma.
6. Diabetic retinopathy — continue annual dilated exam; sooner if any vision change. A1c goal <7.0% in coordination with PCP.
7. Patient education on cataract surgery expectations, post-op drop schedule, activity restrictions for 1 week, and emergency call line.
8. Follow-up: cataract surgery OD in 4 weeks; post-op day 1, week 1, month 1; OS surgery to be re-evaluated 4–6 weeks post-OD if vision drops or symptoms progress.

CPT today: 92014 (comprehensive established), 92250 (fundus photo), 92134 (OCT macula), 92136 (biometry — IOL calc).
Diagnosis pointers: H25.11, E11.3211, E11.3212.

Last reviewed: April 2026 — PatientNotes Clinical Team