Patient: [Patient Name]
Date: [Date of Encounter]
I. Reason for Visit:
Routine diabetic retinopathy screening exam
Follow-up visit to monitor diabetic retinopathy progression
Evaluation of new vision symptoms (blurry vision, floaters, vision loss)
Referral for ophthalmology consultation (suspected advanced diabetic retinopathy)
II. History of Present Illness:
Duration of diabetes mellitus (type 1 or type 2)
Presence of any vision symptoms (blurry vision, floaters, vision loss)
Previous diabetic retinopathy diagnosis and treatment (if applicable)
III. Past Medical History:
Other diabetes complications (neuropathy, nephropathy)
History of high blood pressure
IV. Family History:
Diabetes or eye problems in first-degree relatives
V. Social History:
Smoking history (worsens diabetic retinopathy)
VI. Physical Exam:
Vital signs (BP, HR, RR, Temp)
VII. Ophthalmologic Exam (performed by ophthalmologist or trained technician):
Visual acuity testing
Dilated funduscopic exam:
Assess for microvascular abnormalities (hemorrhages, microaneurysms)
Evaluate macular edema (fluid buildup in the macula)
Assess for signs of advanced diabetic retinopathy (proliferative diabetic retinopathy) – neovascularization (new blood vessel growth), vitreous hemorrhage (bleeding in the vitreous gel)
Intraocular pressure (IOP) measurement (may be done to rule out glaucoma)
VIII. Imaging Studies (performed by ophthalmologist, if indicated):
Fluorescein angiography (FA): Evaluates leakage from retinal blood vessels.
Optical coherence tomography (OCT): Provides detailed cross-sectional images of the retina.
IX. Assessment:
Stage of diabetic retinopathy based on exam findings (no retinopathy, mild non-proliferative diabetic retinopathy (NPDR), moderate NPDR, severe NPDR, proliferative diabetic retinopathy (PDR))
Presence of macular edema
Risk of vision loss
X. Plan:
Management plan may include:
Blood sugar control optimization: Maintaining good glycemic control is crucial to slow disease progression.
Blood pressure control: Medications to achieve and maintain target blood pressure goals.
Referral to an ophthalmologist: For ongoing monitoring and treatment of diabetic retinopathy.
Diabetic retinopathy treatment (performed by ophthalmologist, if indicated):
Laser photocoagulation (laser therapy) to target leaking blood vessels or prevent new blood vessel growth.
Anti-VEGF injections to reduce macular edema.
Vitrectomy surgery (in severe cases) to remove blood from the vitreous cavity.
Diabetic retinopathy screening schedule: Determined by the stage of retinopathy, typically annually for mild to moderate NPDR, more frequent visits for severe NPDR or PDR.
XI. Prognosis:
Discuss the prognosis based on the stage of diabetic retinopathy, response to treatment, and glycemic control.
Early diagnosis and good diabetes management can help prevent vision loss from diabetic retinopathy.
XII. Notes:
Address the patient’s concerns and answer questions about diabetic retinopathy.
Emphasize the importance of regular diabetic retinopathy screening to detect and treat the disease early.
Offer resources for patient education materials or support groups.
XIII. Resources:
Consider providing patient education materials on diabetic retinopathy from reputable sources (e.g., American Academy of Ophthalmology (AAO), American Diabetes Association (ADA)).