Sample Type / Medical Specialty: Ophthalmology
Sample Name: Ophthalmology - Letter - 1
Description: The patient was referred for evaluation of cataracts bilaterally
(Medical Transcription Sample Report)
Dear Dr. XYZ:
Thank you for your referral of patient ABC. The patient was referred for evaluation of cataracts bilaterally.
On examination, the patient was seeing 20/40 in her right eye and 20/50 in the left eye. Extraocular muscles were intact, visual fields were full to confrontation OU, and applanations are 12 mmHg bilaterally. There is no relative afferent pupillary defect. On slit lamp examination, lids and lashes were within normal limits. The conj is quiet. The cornea shows 1+ guttata bilaterally. The AC is deep and quiet and irises are within normal limits bilaterally. There is a dense 3 to 4+ nuclear sclerotic cataract in each eye. On dilated fundus examination, cup-to-disc ratio is 0.1 OU. The vitreous, macula, vessels, and periphery all appear within normal limits.
Impression: It appears that Ms. ABC' visual decline is caused by bilateral cataracts. She would benefit from having removed. The patient also showed some mild guttata OU indicating possible early Fuchs dystrophy. The patient should do well with cataract surgery and I have recommended this and she agreed to proceed with the first eye here shortly. I will keep you up to date of her progress and any new findings as we perform her surgery in each eye.
Again, thank you for your kind referral of this kind lady and I will be in touch with you.
Keywords: ophthalmology, extraocular, applanations, slit lamp, visual field, visual, guttata, surgery, cataracts, eye,