Sample Transcribed Reports:

Ophthalmology . . . Page 2


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  Edited Sample Report

Thank you for sending this woman back for ocular review. I last saw her approximately two years ago and had done cataract surgery on the right eye in August of 1993.

She is now 85 and widowed. She walks regularly and keeping well. She takes a thyroid medication every two days and Inderal and apresoline.

Exam shows best acuity of 20/400 secondary to macular degenerative changes. Her pupils are normal, her pressures are 10. There is a small hemorrhage just inferior to the fovea in the right macula and evidence of old fibrosis and atrophy. The rest of the ocular exam is unchanged.

Diagnosis: No new ocular changes or disease of note apart from a left lower lid marginal chalazion.

I have asked her to use a warm compress on the left lower lid chalazion. There are no other ocular concerns at present but no treatment would, unfortunately, restore her acuity given her current retinal findings. She should continue to be examined periodically to make sure no other ocular disease develops.

  Edited Sample Report

Thank you for sending this gentleman back for ocular review. He was to have undergone cataract surgery in ***, but, in fact, had to cancel because of illness in multiple family members. He now returns complaining of increased trouble with the right vision. Examination shows a vision of 20/40 to 20/50 in the right eye and 20/25 in the left.There is an anterior cortical and nuclear sclerotic cataract. The fundus is unremarkable.

Diagnosis: Increased right cataract.

Mr. * would like to go ahead with surgical correction of the cataract and this will be undertaken with a topical anesthetic and a foldable intraocular lens at the eye care centre in the fall this year.

  Edited Sample Report

Thank you for sending this young woman back. The day of first visit she was complaining of foreign body sensation in the right eye. The previous day she had poked herself in the right eye with a leaf from silal and the eye was extremely irritated.

Exam showed acuity of 20/20 in each eye with +1 perilimbal injection, a stellate inferior epithelial defect in the cornea at approximately 5:00 position with central staining, but no associated infiltrate and no anterior chamber reaction.

I put her on Ocuflox drops every two hours for the first day and then four times a day and also placed her on Muro128 ointment at nighttime to try to get this corneal epithelium to heal. Review one week later showed the epithelial defect to be healed with minimal haze in that region. The Ocuflox was stopped but I asked her to stay on the Muro128 for a further six weeks as vegetable matter abrasions are notoriously poor healing and can lead to recurrent erosions. There is no other significant ocular change and I will see her again only on a p.r.n. basis.

  Edited Sample Report

I have reviewed this patient for her left fundus lesion. It continues to measure approximately 6 x 6 x 2 mm with mild surface subretinal fluid. The margins are unchanged with respect to previous photographs. An ultrasound was performed which showed a lesion height of 2.1 mm which is essentially unchanged from previous measurements over the past 2½ years.

Diagnosis: Stable choroidal nevus/small melanoma.

This lesion does have some subretinal fluid and should be followed carefully, but there are not other worrisome characteristics and it has not shown growth over the last two years. I have asked to see her again in six months' time.

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