Ophthalmology Transcription Services - Sample

John Doe
05/08/04

Subjective:  The patient is a 59-year-old gentleman for evaluation on 02/05/2009.  Cataracts have been noted on routine eye testing, and he was troubled with insulin-dependent diabetes, which was originally diagnosed more than 10 years ago.  He has a prior history of chemical conjunctivitis in both eyes following a lime splash incident 30 years ago.

Objective:  On testing, his corrected acuities were Right Eye: –0.50 –1.00 x 85, 6/6, and Left Eye: –0.25 –1.00 x 90, 6/5.  The right pupil was slightly misshapen; however, it reacted only to light.  There was mild lens sclerosis, and his ocular tensions were 16 mmHg in each eye.  There was no background diabetic retinopathy, and he suffered with tear deficiency.

Assessment and Plan:  We have recommended Refresh Liquigel drops six times daily in both eyes and no intervention on the cataracts at this stage.  A followup assessment has been scheduled in 12 months, and we will report back.

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