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Sample Transcribed Reports:


Ophthalmology . . . Page 1


These reports are samples of basic clinical evaluations of patients seen by an ophthalmologist. The sample reports have been checked for accuracy in spelling, but please keep in mind nobody's perfect, and we do appreciate any notification of errors. These sample medical reports may also include some styles or report formats that are unusual, and if so, this would be due to the preference of the dictating physician.


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  Edited Sample Report

Thank you for sending this patient for review with respect to his diabetes. He has been diabetic since 1989 and does have some peripheral dermopathy.

He had noticed blurring of his vision in his left eye several weeks ago for both distance and near but this has subsequently settled.

His glucometers run between lowest of 6 and highest of 11.

Meds: Accupril, Glyburide, Metformin.

He also complained of a single episode, lasting for five minutes, of horizontal diplopia at approximately a three foot distance which was the only such episode and has not recurred.

Exam showed acuity of 20/20 in the right eye and 20/25 in the left with normal pupils and eye movements. Cross-cover testing showed no eye movement abnormalities. Slit lamp exam shows increasing cataract peripherally in the right eye and centrally on the left. The pressures are 22 bilaterally with no significant evidence of optic disk cupping. There was no diabetic retinopathy of note.

Impressions: 1) Borderline intraocular pressures.
                     2) Modest cataract not yet visually significant.
                     3) No significant diabetic retinopathy.

I believe some of his blurring is the developing cataract and this should be watched. He still qualifies for a driver's licence and I believe examination in one year is soon enough.

  Edited Sample Report

 

Thank you for sending this ***-year-old woman for ocular review. She is noticing some changes in her acuity.

Meds: Imitrex, beta blocker, Naprosyn.

Exam shows best acuity of 20/20 in the right eye and 20/20 in the left with a significant change to the left refraction. She does require a reading adjustment to see small print at near. It also appears that the contact lens is tight and requires refitting.

Impressions:  1)  Myopia.
                     2) Increasing myopia left eye.
                     3) Early presbyopia.

A new prescription was issued. There is nothing else that requires investigation or treatment at this time, but the degree of high myopia suggests she should be examined regularly.

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