John Doe
1 November 2024
History of main complaint:
Patient presents with gradual blurring of vision in both eyes over the past 6 months, worse in the left eye. Reports occasional glare and halos around lights, particularly at night. Denies pain, redness, or discharge. Difficulty with reading and driving.
Past ocular history:
Myopia, bilateral (H52.1).
Past medical history:
Hypertension (I10), well-controlled with medication.
Relevant family history:
Mother had cataracts in her 60s.
Hx of trauma:
None.
Allergies:
Penicillin (T36.0X5A).
On examination:
VA Right Eye:
Distance: 20/40, Near: J3
VA Left Eye:
Distance: 20/80, Near: J7
Autorefraction:
RE: -2.50 +0.75 x 90
LE: -3.75 +1.00 x 170
Keratometry:
RE: 43.50 @ 180 / 44.00 @ 90
LE: 44.25 @ 10 / 45.00 @ 100
Right Eye Examination:
Eyelids and adnexa:
Normal, no oedema or erythema.
Conj/Sclera:
Clear and white.
Cornea:
Clear, no opacities or oedema.
AC:
Deep and quiet, no cells or flare.
Iris:
Normal architecture, no neovascularisation.
Lens:
1+ nuclear sclerosis, minimal posterior subcapsular changes.
Fundus – Right Eye:
Disc:
Pink, sharp margins, C/D ratio 0.3.
Macula:
Flat, no drusen or exudates.
Vessels:
Normal calibre, no haemorrhages.
Retina:
Attached, no tears or detachments.
Left Eye Examination:
Eyelids and adnexa:
Normal, no oedema or erythema.
Conj/Sclera:
Clear and white.
Cornea:
Clear, no opacities or oedema.
AC:
Deep and quiet, no cells or flare.
Iris:
Normal architecture, no neovascularisation.
Lens:
2+ nuclear sclerosis, moderate posterior subcapsular changes.
Fundus – Left Eye:
Disc:
Pink, sharp margins, C/D ratio 0.3.
Macula:
Flat, no drusen or exudates.
Vessels:
Normal calibre, no haemorrhages.
Retina:
Attached, no tears or detachments.
IOP:
RE: 16 mmHg
LE: 17 mmHg
Imaging:
OCT:
RE: Macula and optic nerve head within normal limits.
LE: Macula and optic nerve head within normal limits.
Pentacam:
RE: Normal corneal topography, no ectasia.
LE: Normal corneal topography, no ectasia.
Visual Fields:
RE: Full to confrontation.
LE: Full to confrontation.
Assessment:
Bilateral cataracts, more advanced in left eye (H25.9).
Bilateral myopia (H52.1).
Plan:
1. Discuss cataract surgery options for the left eye, given visual impairment affecting daily activities. Refer to surgical scheduling.
2. Monitor right eye cataract annually.
3. Continue current hypertension management with GP.
4. Follow up in 3 months for pre-operative assessment for left eye cataract surgery and repeat ocular examination.
[Patient name, surname] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Date of consult] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
History of main complaint:
[Insert history of main complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Past ocular history:
[Insert past ocular history with ICD-10 codes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Past medical history:
[Insert past medical history with ICD-10 codes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Relevant family history:
[Insert relevant family history with ICD-10 codes where applicable] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Hx of trauma:
[Insert history of trauma with ICD-10 codes if applicable] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Allergies:
[Insert allergies with ICD-10 codes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
On examination:
VA Right Eye:
[Insert visual acuity right eye] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
VA Left Eye:
[Insert visual acuity left eye] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Autorefraction:
RE: [Insert autorefraction right eye] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
LE: [Insert autorefraction left eye] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Keratometry:
RE: [Insert keratometry right eye] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
LE: [Insert keratometry left eye] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Right Eye Examination:
Eyelids and adnexa:
[Insert findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Conj/Sclera:
[Insert findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Cornea:
[Insert findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
AC:
[Insert anterior chamber findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Iris:
[Insert findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Lens:
[Insert findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Fundus – Right Eye:
Disc:
[Insert findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Macula:
[Insert findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Vessels:
[Insert findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Retina:
[Insert findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Left Eye Examination:
Eyelids and adnexa:
[Insert findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Conj/Sclera:
[Insert findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Cornea:
[Insert findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
AC:
[Insert anterior chamber findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Iris:
[Insert findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Lens:
[Insert findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Fundus – Left Eye:
Disc:
[Insert findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Macula:
[Insert findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Vessels:
[Insert findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Retina:
[Insert findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
IOP:
RE: [Insert intraocular pressure right eye] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
LE: [Insert intraocular pressure left eye] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Imaging:
OCT:
RE: [Insert OCT findings right eye] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
LE: [Insert OCT findings left eye] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Pentacam:
RE: [Insert Pentacam findings right eye] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
LE: [Insert Pentacam findings left eye] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Visual Fields:
RE: [Insert visual field findings right eye] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
LE: [Insert visual field findings left eye] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Assessment:
[Insert assessment with ICD-10 codes for all conditions mentioned] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Plan:
[Insert management plan] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(For each section, only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the section entirely. Never come up with your own patient details, examination findings, diagnoses, investigations, assessment, or plan. Use only the transcript, contextual notes or clinical note as the source of truth. If any information related to a placeholder has not been explicitly mentioned, do not state that it is missing—simply omit the placeholder or section entirely.)
