Patient presents with ocular hypertension, defined as elevated intraocular pressure (IOP) without optic nerve damage or visual field loss.  Risk factors assessed included family history of glaucoma, age, race, and history of myopia.  Current medications were reviewed for potential contribution to elevated IOP.  On examination, IOP measured [insert IOP OD and OS] mmHg via [insert tonometry method, e.g., Goldmann applanation tonometry].  Optic nerve head assessment revealed [describe optic disc appearance, e.g., normal cup-to-disc ratio, no evidence of notching or rim thinning].  Visual field testing [specify test, e.g., Humphrey visual field] showed no detectable defects.  Gonioscopy was performed revealing [describe angle characteristics, e.g., open angles].  Pachymetry readings were [insert central corneal thickness OD and OS] microns.  Assessment: Ocular hypertension.  Plan:  Patient education provided regarding glaucoma risk factors and the importance of regular monitoring.  Baseline visual field and optic nerve imaging [specify imaging modality, e.g., OCT] obtained.  No medical intervention initiated at this time.  Follow-up scheduled in [timeframe, e.g., 3 months] for repeat IOP measurement, optic nerve assessment, and visual field testing.  Patient advised to return sooner if they experience any visual changes.  Differential diagnosis included primary open-angle glaucoma suspect, corticosteroid-induced ocular hypertension, and pseudoexfoliation syndrome.  ICD-10 code H40.10 assigned.