Consult · Nurul Izzah binti Abdul Malik

Summary

Patient

Age · sex: 79y · F · born 10/08/1947
Visit: MalayNo balancePanel · MicareGL RM 90 · over RM 1,949.2

Since last visit · 10 wk

26 Jul 26 · Dr. Michael · Follow Up · Glaucoma IOP 24 mmHg above target on two drops: add a third agent or offer SLT, repeat fields. Review in 2 months. Prescribed Xalatan, Timolol 0.5% 5ml Eye drops.

Last time

VA OD: 6/12 (0.30) (same)
VA OS: 6/9 (0.18) (same)
IOP OD: 24 → 22 ↑ above 15
IOP OS: 14 (same)
CDR: 0.7 · 0.3 (first)

Medicines last time

2

Latanoprost 0.005% OD nocte

Timolol 0.5% OD bd

Record

Alerts & allergies: 1
Active problems: 2
Current medicines: 2
Lab & imaging: 4
Care & screening: 0
Past visit summary: 12

Clinical note

Draft

VA OD 6/12 (0.30)VA OS 6/9 (0.18)IOP OD 22IOP OS 14CDR 0.7 / 0.3

Complaint

Diagnosis

H40.1 Primary open-angle glaucoma On record

VA / Refraction OD OS

Anterior segment OD OS

Fundus OD OS

IOP · target 15 / 21 OD OS

History

Plan (required to sign)

Plan

Assist

1

IOP OD · 22 · 10:20

Allergy on file

Latex (Contact)

Next review

Review 4 wk Suggested 02/11

Follow-up

Orders today

3

Selective Laser Trabeculoplasty (SLT)

Booked

Timolol 0.5% 5ml Eye drops · 1 drop · right eye · twice daily

Current

Latanoprost 0.005% 2.5ml Eye drops · 1 drop · right eye · ON (night)