Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples

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Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Eye Examination - H&P

Description: Complete eye examination - Normal eye and vision exam.
(Medical Transcription Sample Report)

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.

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.
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 O.U.
IOP: IOP Method: applanation tonometry OD: 10 mmHg Medications: Alphagan; 0.2% Condition: improving.
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.

Visual acuity - uncorrected: OD: 20/10 OS: 20/10 OU: 20/15.

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

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.

Keywords: consult - history and phy., eye, pupils, visual fields, confrontation, retina, visual acuity, complete eye examination, eye examination, lens, acuity, visual, vision, os, retinas, od, keratometry, examination,
NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples