Optometry Consultation Notes

Chief Complaint

• Patient reports difficulty reading small fonts, especially on phone and in books.
• Blurriness affects up-close work.

History of Present Illness (HPI)

• Onset: Noticed blurriness about a year ago, gradually worsening.
• Triggers: No specific trigger, gradual onset.
• Variability: Generally constant, worse under dim lighting and sometimes with computer work.

Visual Demands

• Occupation: Accountant, working on a computer approximately 9 hours a day.
• Tasks: Reading spreadsheets and writing reports.
• Setup: Two monitors at arm's length.
• Hobbies: Reading, knitting, both affected by blurriness.

Ocular History

• Last eye exam: Two years ago; no reading glasses prescribed.
• Glasses: Wears glasses for distance; no contact lenses.
• Distance vision: Okay with glasses, but notes it has become more difficult to read through current glasses in recent months.
• Driving: Wears glasses for driving, especially at night.
• Car Navigation: Dash and navigation system are somewhat blurry.
• Eye disease/injuries/operations: None reported.

Medical History

• High blood pressure: Diagnosed three years ago.
• Last GP visit: A couple of months ago (unrelated to high blood pressure).
• Medications: Perindopril 5mg, twice daily for high blood pressure.
• Family history of diabetes: Father has diabetes and is on medication (name unknown).

Family Ocular History

• Sister: Very short-sighted, strong glasses.
• Brother: Also short-sighted, but less so than sister.
• Father: Glaucoma.
• Macular degeneration: No family history.

Allergies

• No known medication allergies.

Medications/Supplements

• Takes multivitamins once a day.

Social History

• Does not identify as Aboriginal or Torres Strait Islander person.