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.

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.
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.
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.

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

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,