Dr. Austin Ekeoba
Back to chart · Amara Okonkwo

comprehensive encounter

complete Locked
November 25, 2025 at 1:40 p.m. · Dr. Austin Ekeoba · 40 min
Encounter locked. The clinical record is immutable. Locked Nov 26, 2025 by Dr. Austin Ekeoba. New observations may be added as an addendum below.

Subjective

Chief complaint
Diabetic retinopathy screening.
HPI
44F T2DM x12y on insulin. Last A1c 7.4. Asymptomatic vision-wise.

Objective

VA (cc)
OD20/25
OS20/20
IOP (NCT) · 13:40
OD15 mmHg
OS14 mmHg
Fundus / DFE
Disc OD C/D 0.4 · Pink, sharp.
Disc OS C/D 0.4 · Pink, sharp.
Macula OD Few dot heme temporal
Macula OS Few dot heme temporal

Assessment & Plan

Assessment
  • •Mild NPDR OU
  • •T2DM with A1c 7.4
Plan
  • •Continue annual DR screening
  • •Reinforce glycemic control with PCP
  • •OCT macula obtained — no CSME
  • •RTC 12 months or sooner if symptoms