home work

Patient Case

Head, Ears, and Eyes Assessment (Glaucoma)

Subjective Data:

Mr. Harold, a 68-year-old African American man

Reason for visit: routine annual physical examination.

Medications: blood pressure medication (enalapril), a cholesterol lowering agent (atorvastatin), and eye drops (timolol).

He reports an allergy to shellfish.

Social history: he is a school bus driver.

Medical History: 5-year history of glaucoma

He states that his vision seems worse than usual in both eyes, particularly the last 2 months. Ask Mr. Harold more PQRSTU about his symptoms

Physical Exam (Objective Data):

Vital Signs: Oral Temp 37 C, HR 86 BPM, RR 16, and BP 118/68 mm Hg

Head: all appear normal – document a normal/expected head assessment

Ears: al appear normal- document a normal/expected ear assessment

Eyes:

· Inspection: document as normal/expected.

· Vision testing: right 20/30, left 20/50.

· Document any other findings as normal/expected