HPI: A 45 year-old male with hx of DM Type 2 x 15 years and hypercholesterolemia presents to the Eye Clinic for his annual visit. He states that he has noticed some progressive blurring of vision since his last visit one year ago. Reading street signs while driving seems more difficult. He is unsure of which eye seems worse. He does not wear any glasses or contacts with the exception of over-the counter reading glasses. He denies any flashes or floaters, any eye discomfort, or any recent eye pain.
The patient reports that he has been going through some tough times recently with a difficult divorce about 6 months ago. As a result of all the stress, his blood sugars have not been under good control and he feels he has been making this worse by eating a lot of junk food and not always taking his diabetic medications. His blood sugar has been as high as 400 and he was admitted to the hospital three months ago for diabetic ketoacidosis.
POHx: No previous history
PMHx: Hypercholesterolemia, Obesity, DM Type 2, Hypertension
Ocular Medications: None
Other Medications: Lisinopril, HCTZ, metformin, simvastatin
FHx: Mom – DM Type 2; Dad- DM Type 2, hypertension, MI at age 52; Brother - Hypercholesterolemia
SocHx: He has a 30 pack year smoking history and drinks alcohol socially
ROS: Negative besides complaints presented in the HPI