Sample Type / Medical Specialty: Ophthalmology
Sample Name: Ophthalmology Progress Note - 1
Description: Ophthalmology followup visit note.
(Medical Transcription Sample Report)
Visual acuities at this date were measured at 20/25 in the right eye and 20/20 in the left eye with correction. Pupils were equal, round, and reactive to light with no afferent pupillary defects. Extraocular muscle movements were smooth and full. Intraocular pressures were measured at 18 mmHg in the right eye and 20 mmHg in the left eye, by applanation. A dilated fundus examination was performed using a 20-diopter lens with the binocular indirect ophthalmoscope. The examination revealed retinal pigmentary epithelial changes in both eyes with no holes, tears, or detachments apparent around 360 degrees of either retina.
She is stable at this time and does not require any intervention at today's visit. I have asked her to return in six months' for a followup dilated examination, but would be happy to see her sooner should you or she notice any changes in her vision.
Keywords: ophthalmology, visual acuities, extraocular muscle, intraocular pressure, pupils, afferent, applanation, binocular, dilated fundus, left eye, lens, movements, ophthalmoscope, pigmentary, retina, retinal, right eye, acuities,