Sample Transcribed Reports:

Ophthalmology . . . Page 5

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  Edited Sample Report

Thank you for sending this **-year-old woman complaining of her vision being blurred, especially with reading, and in the right eye more than the left. She also feels as if the right eye is puffy; the eye is watering. She still drives a vehicle and has no difficulty doing that with her glasses which are three years old.

Medical History: Angina. Skin cancer with a graft to the nose.

Ocular History: Unremarkable.

Family History: Father with cataracts.

Meds: Nitrong, Acebutolol.

Allergies: ASPIRIN causing GI upset.

With her current spectacles her vision is 20/50 in both eyes. A refractive change improves that to 20/40 in the right and 20/30 in the left. She has central corneal guttate with mild pigmentation and cataracts which are not dense enough to be entirely responsible for the acuity. The pressures are normal. The left iris shows a small ectropion uvea at the 4:30 to 5:00 position and a small translucent nodule with adjacent pigment flecks on the iris surface. The fundus shows some soft drusen with pigmentation and atrophy in both fundi.

Impressions: 1) Small iris melanoma, right eye.
                     2) Age-related macular degenerative changes.
                     3) Mild cataracts.

I have sent her for a photograph of the iris changes. What is there at present is very mild and does not require intervention but does need good documentation and follow-up. She does have cataracts but it is the combination of the cataract of the macular changes not the cataract alone which is making her vision blurred. At this point in time, there is no treatment required to the macular degeneration but, again, she should be followed in six months for the combination, especially if she is still driving. I have also changed her prescription on this occasion.

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  Edited Sample Report

Thank you for sending this **-year-old cashier complaining of intermittent blurring which lasts all day, not associated with any pain which onset about July of 1998. This appears as if there may be mucous in the eye but there is actually nothing there. It happens to the left eye only. There is no scotoma. Initially, there was associated photopsias but these have gone. There is no history of trauma.

Medical History: ? rheumatoid arthritis.

Ocular History: Unremarkable.

Family History: Mother with cataracts.

Meds: Premarin, Provera, Tylenol.

Allergies: SULFA.

Acuities best corrected are 20/15 in the right eye and 20/20+ in the left. Eye movements are full. Pupils were normal. The slit lamp exam showed some mild pigment dusting on the lens capsule of the right eye only with no transillumination defects of the iris and some mild pigmentation on the iris in both eyes. The intraocular pressures were 15. The dilated fundus exam showed a posterior vitreous detachment in the left with no holes, tears or retinal detachment. There was an obvious Weiss ring and a few drusen at the fovea.

Diagnosis: Posterior vitreous detachment left eye. Hyperopia left eye.

I could find no abnormality of the macula itself. The vitreous detachment has left a fairly large floater centrally located in the left eye which I think is causing her blurring. She does not require any treatment to it and there is nothing sight threatening about this condition and I have explained it and reassured her. The distance refraction in the left eye is only minimal and I would not currently put her into glasses at this level.

  Edited Sample Report

Thank you for sending this delightful **-year-old woman who does not drive a vehicle and sees well enough to do her tasks around home and to look after her own mail. She was told in the past that she had cataracts.

She did have an episode where she fell unexpectedly on her face last year and was unsure of the reason initiating the fall. She apparently broke her nose but has not had any falls since then and does not think there was anything in the way of visual disturbance causing the fall.

Medical History: Hypertension. Insomnia.

Ocular History: Unremarkable.

Family History: Nil of note.

Meds: Enalapril.

Allergies: None.

Exam shows uncorrected acuity of 20/50 right and 20/80 left. This improves to 20/30 with best correction. Her pupils are normal, eye movements are full and slit lamp exam shows exfoliation syndrome in both eyes. The intraocular pressure was 21 right and 22 left. The fundus exam showed a cupped disk on the right side .8 to .9 verticallyx .7 with temporal rim missing. The left was less cupped at .7 x .6. There was also myopic crescent but no other fundus abnormalities.

Impressions: 1) Bilateral cataracts, mild.
                     2) Exfoliation syndrome with probable glaucoma.

I have sent her for a Goldmann visual field first of all to substantiate any changes. Although her pressures were not high when I saw her, I suspect they have been in the past and it is the visual field and its changes rather than the cataract that is causing some of the visual loss. I will see her again once the field test results are available and advise you of our plans after that.

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  Edited Sample Report

Thank you for sending this **-year-old woman who appears much younger than her stated age. She helps run a family business at home and organizes the lives of her family including a very bright young son. She has had a rather unusual problem.

She comes for ocular review because she gets aching around and behind the left eye and over the left malar area in conjunction with episodes of shingles. However, the shingles affect the left trunk, show up in a definite dermatome patch in the lumbar area and there have never been associated vesicles or redness in the trigeminal distribution. There is no associated redness or discharge with the aching but she does become photophobic.

The first episode of the zoster occurred three years ago while she was away hiking. The second episode occurred last year in November. Subsequently, she has had one in January, two in September and one in November of this year. She never gets the orbital ache without the episodes of zoster and each time she gets the zoster there are vesicles to see and some numbness or tingling. She has not had associated labial herpes, cold sores or other abnormalities. There is no history of facial fractures or injuries. There is no history that sounds like thyroid disease.

Medical History: Otherwise well.

Ocular History: Unremarkable.

Family History: Mother with Type II diabetes.

Meds: Valacyclovir or famciclovir.

Allergies: None known.

Ocular exam shows a decrease in her refractive error with best corrected acuity of 20/15 in both eyes. The ocular, orbital and facial neurologic exam was completely normal in both eyes. There was no evidence of redness, no abnormal corneal vasculature or scarring, no facial scars or lesions, no change in her hearing, and no change in the corneal sensation. There was no evidence of proptosis. The intraocular pressures were 18 bilaterally and the anterior chambers showed no evidence of inflammation. There was no evidence of previous uveitis or iritis episodes. The dilated fundus exam showed absolutely no abnormalities at the vitreous, choroid or optic nerve.

Impressions: 1) Mild refractive change.
                     2) Suspect migraine equivalent.

She may have something resembling cluster migraine brought on by these episodes, although she has no history of it in the past. I do not find any zoster-like effects around the eye and I am somewhat puzzled by the overall syndrome. I have suggested to her that she should see Dr.**** and apparently arrangements have already been made for this. The frequency of the zoster recurrence is in the absence of the uncompromising disease also seems a little unusual and I am sure Dr. **** will help to sort this out.

If sorting out the zoster does not completely alleviate her symptoms, a neurologic evaluation is probably in order. The other alternative is that she develop unilateral photophobia which is extremely variable in nature and can be brought on by anything including headache, neurologic disturbance or general illness and this is what she is complaining of around the left eye.

I will look forward to hearing from you as to the final outcome of this. If I can be helpful in any other way, please don't hesitate to contact me.

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  Edited Sample Report

I have seen this woman for ocular review. The problem she was having when I saw her in September with a fairly severe pain behind her left eye for four days have completely resolved. I had sent her for an ultrasound of her orbit which demonstrated the scleral buccal but no other abnormality. There was no evidence of scleritis, vascular dilation, masses behind the globe. There were mild effects on the lateral rectus muscle probably secondary to effects from the buccal causing a mild myositis. I did not put her on any medications when I saw her but I did ask for a CT scan of the region.

On review, she was still having some foreign body sensation in the left eye but there was no recurrence of the severe pain. She has not had diplopia at any time during this. The scleral buccal has been present since 1991.

Exam showed mild meibomian plugging but no crusting in the lashes. The eye movements were full, there was no redness over the muscles, no staining of the cornea and no anterior chamber reaction. The pressure was 13. Her scleral buccal was quite close to the lacrimal gland and causing some distortion of the conjunctiva in that region.

Impressions: 1) Mild meibomitis.
                     2) Mild dry eye.
                     3) No other obvious significant disease.

I have put her on lid hygiene and Artificial Tears at least four times a day to try and relieve her symptoms, but things are much better than they were in September and whatever the major problem was, seems to have subsided. Nonetheless, at that time I requested a CT scan of the posterior orbit and will carry through with this to make sure we have ruled out other significant disease that may return. During this episode, I have never seen findings that I would specifically classify as myositis and I suspect that she had some difficulties around the buccal causing the pain as opposed to anything else. There is no evidence of the buccal being infected and I would definitely not recommend its removal.

I will see her once in follow-up. If I can provide any further assistance, please don't hesitate to contact me.

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  Edited Sample Report

Thank you for sending along this **-year-old woman. You had noticed a pigmented lesion in her right fundus and have sent her for an ultrasound and a fluorescein.

She herself has not noticed anything except being slightly bothered by glare. She is Polish in origin and has lived in *** for three years, but has no history of excess outdoor exposure to sun, no skin lesions of any note and no family history of melanomas.

Medical History: Hypertension. Back pain.

Ocular History: Injured with a snowball with ice at about age ten; can't remember which eye was required to be covered for approximately six weeks at that time.

Meds: Atenolol, hydrochlorothiazide.

Exam shows acuity of 20/20- in the right eye and 20/20 in the left. There is a fleck of exophoria. There is an old scar in the right cornea that I think corresponds to her snowball injury. She has pingueculae in both conjunctiva. Pupils are normal. The irises are hazel. She has several ephelides on the right iris but no nodules or iris melanomas.The pressures are 14.

Dilated fundus exam in the right eye showed a lesion just above and slightly under the supratemporal vascular arcade measuring 10 x 8 x 2 mm. It had mottled brown appearance with drusen over its surface and no subretinal fluid or worrisome characteristics. However, right at the lower margin of it there was multiple intraretinal hemorrhages consistent with a branch vein occlusion. I could not pinpoint the actual branch occluded. Her general vessels in this eye and the other showed only mild arterial venous narrowing and nicking. The left eye showed mild macular wrinkling just supratemporal to the fovea.

Impressions: 1) Right choroidal small melanoma. Ultrasound height 2.1 mm.
                     2) Right branch retinal vein occlusion.
                     3) Left epiretinal membrane.

The branch vein occlusion was new compared to your exam. I sent her for a fluorescein angiogram which confirmed this. I have asked her to come to see you in one month's time and subsequently for follow-up, but at present, there is no cystoid macular edema and I would not recommend any laser intervention. The left epiretinal membrane is not interfering with acuity. I would like to see her about the pigmented lesion in six months' time.

  Edited Sample Report

Thank you for sending this lady for ocular examination. She has undergone previous bilateral cataract surgery under Dr. ****. She experienced sudden loss of vision in both eyes which recovered in the right eye, but has left her with poor vision in the left. Her description is that the vision disappeared in both eyes, although I suspect that it disappeared in one eye only and was noticed on a relatively acute basis.

I discussed the patient with you on the phone. You had notes that Dr. **** had acuities of 20/30 in the right eye and 20/400 in the left in **** of 1997, and that there was a diagnosis of a central retinal artery occlusion in the left. She was reviewed again in **** of 1998, and things were stable.

Medical History: Cardiac dysrhythmia. Hypertension. "Sudden" deafness bilaterally with recovery in the right, investigated by ENT.

In both the vision and hearing loss, there was, apparently, no suspicion of polymyalgia rheumatica or temporal arteritis.

Family History: Unremarkable.

Meds: Adalat, Coumadin, digoxin, furosemide.

Allergies: None.

Exam showed best corrected acuity with a myopic astigmatic refraction of 20/25 in the right eye and 20/40 in the left. Eye movements were full. There was an obvious left relative afferent pupillary defect. Posterior chamber intraocular lenses were seen in good position in both eyes with pressures of 16 bilaterally. The dilated fundus exam showed a few central macular drusen and choroidal sclerosis in both fundi. The optic disk was pale on the left. The rest of the ocular exam was unremarkable.

Impressions: 1) Bilateral pseudophakia.
                     2) Old, left, central retinal artery occlusion.

I reassured the patient that her vision in her right eye and with both eyes open was excellent. The left eye had remarkable acuity recovery probably because of the retinal vessel which provided good central acuity. I suspect she may have some loss of retinal sensitivity consistent with her afferent defect all on the basis of the previous central artery occlusion, but she nonetheless has useful vision in the eye. Nothing further in the way of investigation or treatment is required and I reassured her of this. I also gave her a copy of the prescription for distance which may be of some help to her.

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