眼科标准英文病历( 眼科检查)

眼科标准英文病历( 眼科检查) Charting Plus? - Electronic Medical Sample History and Physical Note Records Note for John Doe on 6/6/02 - Chart 1124 Chief Complaint: This 26 year old male presents today for a complete eye examination. Allergies: Patient admits allergies to aspirin resulting in disorientation, GI upset. Medication History: Patient is currently taking amoxicillin-clavulanate 125 mg-31.25 mg tablet, chewable medication was prescribed by A. General Practitioner MD, Adrenocot 0.5 mg tablet medication was prescribed by A. General Practitioner MD, Vioxx 12.5 mg tablet (BID). PMH: Past medical history is unremarkable. Past Surgical History: Patient admits past surgical history of (+) appendectomy in 1989. Social History: Patient denies alcohol use. Patient denies illegal drug use. Patient denies STD history. Patient denies tobacco use. Family History: Unremarkable. Review of Systems: Eyes: (-) dry eyes (-) eye or vision problems (-) blurred vision Constitutional Symptoms: (-) constitutional symptoms such as fever, headache, nausea, dizziness Musculoskeletal: (-) joint or musculoskeletal symptoms Eye Exam: Patient is a pleasant, 26 year old male in no apparent distress who looks his given age, is well developed and nourished with good attention to hygiene and body habitus. Visual Acuity: Visual acuity - uncorrected: OD: 20/10 OS: 20/10 OU: 20/15 Refraction: Lenses - final: OD: +0.50 +1.50 X 125 Prism 1.75 OS: +6.00 +3.50 X 125 Prism 4.00 BASE IN Fresnel Add: OD: +1.00 OS: +1.00 OU: Far VA 20/25 Pupils: Pupil exam reveals round and equally reactive to light and accommodation. Motility: Ocular motility exam reveals gross orthotropia with full ductions and versions bilateral. Visual Fields: Confrontation VF exam reveals full to finger confrontation OU. IOP: IOP Method: applanation tonometry OD: 10 mmHg Medications: Alphagan; 0.2% Condition: improving. Keratometry: OD: K1 35.875K2 35.875 OS: K1 35.875K2 41.875 Lids/Orbit: Bilateral eyes reveal normal position without infection. Bilateral eyelids reveals white and quiet. Slit Lamp: Corneal epithelium is intact with normal tear film and without stain. Stroma is clear and avascular. Corneal endothelium is smooth and of normal appearance. Anterior Segment: Bilateral anterior chambers reveal no cells or flare with deep chamber. Lens: Bilateral lenses reveals transparent lens that is in normal position. Posterior Segment: Posterior segment was dilated bilateral. Bilateral retinas reveal normal color, contour, and cupping. Retina: Bilateral retinas reveals flat with normal vasculature out to the far periphery. Bilateral retinas reveal normal reflex and color. Test Results: No tests to report at this time Impression: Eye and vision exam normal. Plan: Return to clinic in 12 month(s). Patient Instructions: Patient was given verbal and written instructions regarding eye care following pupil dilation. __________________________________ Dr. An. Ophthalmologist, MD Charting Plus? - Electronic Sample Referral Letter Medical Records 6/6/02 Marcus Welby, M.D. th1231 8 Street, Suite 222 West Des Moines, IA 50265 Dear Dr. Welby: John Doe was seen in my office in consultation as requested by you as a new patient for evaluation and care. The following is a summary of my findings and recommendations: Impression: Eye and vision exam normal. Plan: Return to clinic in 12 month(s). If I may be of any further assistance in the care of your patient, please let me know. Thank you for providing me the opportunity to participate in the care of your patients. Sincerely, An. Ophthalmologist, MD Charting Plus? - Electronic Sample Prescription Medical Records Dr. An. Ophthalmologist, MD DEA#: _________________________________________________________ Name: John J Doe Date: 6/6/02 OD: +0.50 +1.50 X 125 Prism 1.75 OS: +6.00 +3.50 X 125 Prism 4.00 BASE IN Fresnel Add: OD: +1.00 OS: +1.00 Dr._____________________________________________ Charting Plus? - Electronic Sample Billing Statement Medical Records Billing Statement - Thursday, June 06, 2002 Provider: An. Ophthalmologist, MD Patient: John J Doe, Chart 1124 123 E. Freckle St. Jersey City, NJ 07040 Diagnoses 1. V72.0 Examination Of Eyes And Vision Treatments 1. 99213 Office or other outpatient visit - est. patient - 15 min. Related Diagnoses: V72.0 Modifiers: Units: Referring Physician: A. General Practitioner, MD Date Last Seen: 07/26/2001 Charting Plus? - Electronic Medical Sample Patient Instructions Records Patient Instructions for John Doe on 6/6/02 YOUR EYES HAVE BEEN DILATED Dilation drops temporarily increase the size of your pupils. This lets us accurately investigate the health of your eyes and other important general health aspects. Dilation of your eyes is a temporary inconvenience; however, benefits far outweigh the inconvenience. The effects of eye dilation drops will gradually decrease. It typically takes TWO to SIX HOURS for the effects to wear off. During this time, reading may be more difficult and sensitivity to light may increase. For a short time, wearing sunglasses may help. Notify us if you feel your long distance vision is blurred excessively before attempting to drive. Your patience during this very important procedure is appreciated! CALL MY OFFICE IMMEDIATELY AT 515-327-8850 IF YOU EXPERIENCE EXCESSIVE PAIN, DISCOMFORT OR NAUSEA REMEMBER TO HAVE REGULAR MEDICAL EYE EXAMINATIONS. Eye disease can occur at any age. Since most blindness is preventable if diagnosed and treated early, it is extremely important to have regular eye examinations. Keep in mind that many eye diseases are asymptomatic until after the damage to the eye has already occurred so early detection is the key. Use this as a reminder to plan for regular eye examinations to maintain sight throughout a lifetime. _______________________________An. Ophthalmologist, MD CATARACT What is a cataract? * A cataract is the loss of transparency of the lens of the eye. It often appears like a window that is fogged with steam. What causes cataract formation? * Aging, the most common cause. * Family history. * Steroid use. * Injury to the eye. * Diabetes. * Previous eye surgery. * Long-term exposure to sunlight. How do I know if I have a cataract? * The best way for early detection is regular eye examinations by your medical eye doctor. There are many causes of visual loss in addition to the cataract such as problems involving the optic nerve and retina. If these other problems exist, cataract removal may not result in the return or improvement of vision. Your eye doctor can tell you how much improvement in vision is likely. Does it take a long time for a cataract to form? * Cataract development varies greatly between patients and is affected by the cause of the cataract. Generally, cataracts progress gradually over many years. Some people, especially diabetics and younger patients, may find that cataract formation progresses rapidly over a few months making it impossible to know exactly how long it will take for the cataract to develop. What is the treatment for cataracts? * The only way to remove a cataract is surgery. If the symptoms are not restricting your activity, a change of glasses may alleviate the symptoms at this time. No medications, exercise, optical devices or dietary supplements have been shown to stop the progression or prevent cataracts. It is important to provide protection from excessive sunlight. Making sure that the sunglasses you wear screen out ultraviolet (UV) light rays or your regular eyeglasses are coated with a clear, anti-UV coating will help prevent or slow the progression of cataracts. How do I know if I need surgery? * Surgery is considered when your vision is interfering with your daily activities. It is important to evaluate if you can see to do your job and drive safely. Can you read and watch TV in comfort? Are you able to cook, do your shopping and yard work or take your medications without difficulty? Depending on how you feel your vision is affecting your daily life, you and your eye doctor will decide together when it is the appropriate time to do surgery. What is involved with cataract surgery? * This surgery is generally performed under local anesthesia on an outpatient basis. With the assistance of a microscope, the cloudy lens is removed and replaced with a permanent intraocular lens implant. Right after the surgery you should be able to immediately perform all your normal activities except for the most strenuous ones. You will need to take eye drops as directed by your eye doctor. Follow-up visits are necessary to make sure the surgical site is healing without problems. This procedure is performed on over 1.4 million people each year in the United States alone, 95% without complications. With this highly successful procedure, 90% of the time vision improves unless a problem also exists with the cornea, retina or optic nerve. As with any surgery, a good result cannot be guaranteed. _______________________________ An. Ophthalmologist, MD