Sample Transcribed Reports:

Ophthalmology . . . Page 4

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  Edited Sample Report

Thank you for sending this ***-year-old high school teacher for ocular review. He had experienced a hordeolum in the right lower lid this summer and wanted his eyes examined.

Examination confirmed a right lower lid hordeolum with minimal surface pointing. He had a similar lesion in the left eye previously. I was also noticing a left lower lid chalazion of which he had been unaware. The rest of his ocular exam shows an increase in his mild hyperopia plus presbyopia. The facial examination shows acne rosacea which is undoubtedly responsible for his lid changes. The rest of the exam is unremarkable.

I placed this patient back on a course of doxycycline to clear the rosacea and the lid changes. I have asked him to use warm compresses three times a day if any further lid lumps appear. I would not pursue incision and drainage at this time.

He will require strengthening of his reading spectacles and may eventually come to need a distance spectacle as well, but the eyes are, otherwise, basically normal.

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  Edited Sample Report

Thank you for sending this ***-year-old counsellor for regular ocular review. She wears contact lenses and feels they are less strong than what is needed, but that allows her to read adequately. She is also noticing some eyestrain when using a computer.

She has been using an appropriate care and cleaning system for her lenses.

Medical History: Well.

Ocular History: Otherwise unremarkable.

Family History: Mother with ? macular degeneration.

Meds: Estrogen, Progesterone.

Allergies: None known.

Exam shows acuity with her old spectacles of 20/50 in the right eye and 20/40 in the left. Best corrected acuity is 20/15 in both eyes. The contact lenses appear quite large but they fit and move appropriately. The pupils are normal. Slit lamp exam is unremarkable with no evidence of contact-lens-related complications. The pressures are 10 bilaterally and the fundi are unremarkable.

Impressions: 1) Myopia.
                     2) Refractive change.
                     3) Presbyopia.

We discussed the possibility of mono vision contacts, that is, one eye to read and one eye for distance or the possibility of using a reader over the contact lenses which she would like to avoid. I have given her the names of some good contact lenses fitters. I see no other ocular disease of note and no suggestion of early macular degeneration.

She should have her eyes reviewed in two years' time.

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  Edited Sample Report

I know well this mutual patient who has had pars planitis and whom I have been following since August of ****. Pars planitis is an inflammatory disease in the posterior segment which tends to be self-limited, but can produce vitreous hemorrhages because of vascularization of inflammatory deposits in the peripheral retina. That was how this patient initially presented.

As of October **, ****, she had acuity of 20/15 in the right eye and 20/25 in the left secondary to mild cataract changes which have come with her treatment and inflammation. There is no active anterior segment inflammation but the right vitreous does show some red blood cells. Dilated fundus exam shows several inferior snowballs in the left vitreous but no obvious vitreous or vascular changes in the right fundus.

Diagnosis: Currently, quiescent pars planitis.

The red cells signify possible activity in the right eye but nothing drastic enough to warrant exam under anethesia which is what it would take for treatment in this ***-year-old. She is stable and doing well and I have simply asked to review her again in two months' time. Her last EUA was in June of ****, and I would like to delay the next one until it is essential

  Edited Sample Report

Thank you for sending this ***-year-old clerk to my attention. She had white discharge from both eyes and stickiness in the morning in September. There was no associated redness, pain or itching. There was some mild blurring and at the time she also had an upper respiratory infection. All of this has subsequently resolved.

She currently drives without spectacles.

Acuity is 20/25 right and 20/30- left uncorrected. Best corrected is 20/20 in each eye. Slit lamp exam showed no evidence of conjunctivitis, allergic changes or corneal changes.

Diagnosis: Resolved ? viral conjunctivitis or allergic change.

There is nothing here now which requires treating and I have reassured this patient.

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  Edited Sample Report

Thank you for sending this **-year-old retired judge for ocular examination. Three to four months prior to his exam he had suffered a stroke which impaired his speech, his left arm and his leg, but was resolving by the time I saw him. For this, he was cared for in California.

He was complaining of gradual blurring of the vision in both eyes and difficulties reading. This seemed to be extremely variable.

Medical History: Hypertension. Stroke in May, ****.

The history was somewhat rambling, but it appeared that in California he had some sort of pain in his legs that led to evaluation by a geriatrician and placing the patient on Ticlid. He uses a cane because he's afraid to lose his balance. He also notes blurring of the right eye in episodes in the past and is quite definite that it is only the right eye. The sudden episodes of balance-loss are not necessarily in conjunction with the vision change.

He has also been evaluated for jaundice because of medication and this was eventually found to be colistatic secondary to the Ticlid.

In addition, he has been evaluated by a general vascular surgeon and found to have leg claudication and by carotid Dopplers in November ****, which were apparently normal.

Meds: Antihypertensive; ? anti-stroke agent; no Aspirin.

Allergies: None known.

Exam shows vision of count fingers in the right eye and 20/40 in the left. I could not improve the vision in the right eye. The eye movements are full, pupils were normal and the confrontation visual fields appeared to be full in both eyes. The slit lamp exam shows peripheral marginal degeneration of the cornea bilaterally, especially superiorly and peripheral cataracts, not enough to account for the acuities. Intraocular pressures were 12 bilaterally.

The dilated fundus exam showed evidence of an old vitreous hemorrhage in the right eye. The disk was abnormal with thinning of the neuroretinal rim and the supratemporal region and very narrow arterioles. The left fundus showed epiretinal membrane adjacent to the macula and a normal-looking disk.

Impressions: 1) Evidence of vitreous hemorrhage right eye.
                     2) Epiretinal membrane, left eye.
                     3) Disk changes, right eye; ? glaucoma vs. anterior optic nerve disease.

I arranged for a Goldmann visual field and a fluorescein angiogram and am awaiting these results. I will get back to you when I have a more definitive diagnosis, but the patient himself is entirely correct in saying that his acuity is abnormal in the right eye.

  Edited Sample Report

Thank you for sending this **-year-old student who has noticed a movement disorder of his left hand and leg over many years. Many times a day, especially when initiating a movement he gets an intermittent posturing of the left hand and leg. This problem never wakens him from sleep and does not interfere with the movement once it has been initiated. He is able to play the piano with no difficulties. There is no history of prematurity, family history of a similar disease, infantile seizures or febrile illness.

You have investigated him for Wilson's disease and, apparently, he had a negative blood test.

Medical History: Otherwise well.

Ocular History: Myopia.

Family History: Unremarkable.

Meds: None.

Allergies: None.

Exam shows mild myopia with best corrected acuity of 20/15 in both eyes. His stereo vision, eye movements and pupils are normal. There is no nystagmus or eye movement disorder, specifically no abnormalities of vestibuloocular response, opticokinetic response, saccade, or pursuit. Confrontation visual fields are full.

On slit lamp exam there is minimal iridescence of the inferior corneas with no definitive deep corneal deposit as one would normally see in Wilson's disease. His intraocular pressures, anterior chambers and fundus are otherwise unremarkable.

Impressions: 1) No evidence of Kayser-Fleischer ring.
                     2) Mild myopia.

I cannot confirm any findings of Wilson's disease in this interesting young man and there are no associated ocular coordination or movement abnormalities.

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