Eye Examination
History and Symptoms:
The patient presents with a chief complaint of blurry vision in the left eye, which started approximately one week ago. The blurriness is intermittent, worse in the mornings, and improves slightly throughout the day. There is no associated pain, redness, or discharge. The patient denies any history of trauma.
General Health:
The patient is a 62-year-old male with a history of hypertension, well-controlled with medication. He is otherwise in good health.
Medication:
The patient is currently taking Lisinopril 20mg daily for hypertension.
Previous Ocular History:
The patient had a routine eye examination two years ago, with no significant findings. He wears reading glasses.
Family Ocular History:
The patient's mother has a history of age-related macular degeneration.
Allergies:
The patient has no known allergies.
Occupation:
The patient is retired.
Current Prescription:
The patient uses over-the-counter reading glasses (+1.50). Last eye exam was two years ago.
Refraction:
Visual acuity:
Right eye: 20/20 with +1.50
Left eye: 20/40 with +1.50
Supplementary Tests:
No supplementary tests were performed during this examination.
External Eye Examination:
Eyelids and lashes: Normal.
Conjunctiva: Clear, no injection.
Cornea: Clear.
Iris: Normal.
Pupils: Equal, round, and reactive to light.
Internal Eye Examination:
Optic disc: Normal, with good cup-to-disc ratio.
Macula: Normal.
Retinal vessels: Normal.
Peripheral retina: Normal.
Tonometry:
Intraocular pressure:
Right eye: 14 mmHg
Left eye: 15 mmHg
Advice:
The patient was advised to schedule a follow-up appointment with an ophthalmologist for further evaluation of the blurry vision in the left eye. He was also advised to continue using his reading glasses as needed. The patient was educated on the importance of regular eye examinations.
Date: 1 November 2024
History and Symptoms:
[describe the patient's presenting symptoms, their onset, duration, character, aggravating and alleviating factors, and any associated symptoms, including reasons for the current eye examination] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
General Health:
[document relevant systemic health conditions, chronic diseases, recent illnesses, or general health concerns that may impact ocular health] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Medication:
[list all current medications, including prescription drugs, over-the-counter medications, supplements, and herbal remedies, along with their dosages and frequency] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Previous Ocular History:
[detail any past eye conditions, surgeries, injuries, treatments, or previous eye examinations, including outcomes and dates] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Family Ocular History:
[record any significant eye conditions or diseases present in the patient's family, noting specific relatives and their conditions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Allergies:
[list all known allergies, including medications, environmental allergens, and food allergies, and describe any reactions experienced] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Occupation:
[describe the patient's current occupation and any visual demands or hazards associated with their work environment] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Current Prescription:
[record details of the patient's current spectacle or contact lens prescription, including type, power, and date of last prescription] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Refraction:
[document objective and subjective refraction findings for both eyes, including sphere, cylinder, axis, and visual acuity with and without correction] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Supplementary Tests:
[describe any additional diagnostic tests performed, such as visual fields, optical coherence tomography (OCT), corneal topography, or other specialized investigations, and their findings] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
External Eye Examination:
[detail findings from the examination of the eyelids, lashes, conjunctiva, sclera, cornea, iris, and pupils, noting any abnormalities or signs of disease] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Internal Eye Examination:
[describe findings from the dilated fundus examination, including the optic disc, macula, retinal vessels, and peripheral retina, noting any pathologies or significant observations] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Tonometry:
[record intraocular pressure measurements for both eyes using the method employed, and note any relevant findings or concerns] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Advice:
[summarize all advice given to the patient regarding their ocular health, management plan, follow-up recommendations, lifestyle modifications, and any prescribed treatments or referrals] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
