Eye Exam

Dr. { } is the attending physician with whom the case and plan were discussed and agreed upon.

    Patient Phone #: ({ }) { }-{ }

    Patient E-mail: { } 

<: SUBJECTIVE :>

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(CC): { }

(HPI):

{ When it started, what it's like, better/worse, medications for relief? }

REVIEW OF SYSTEMS:

  Denies {}Floaters/Flashers //retinal detachment/tears

  Denies {}Transient vision loss //migraine vessel spasm (young) / Micro-emboli (elderly)

  Denies {}Blurry vision //night/glare? (cataracts), TV? (dry eyes)

  Denies {}Red painful eyes

  Denies {}Eye discharge

  Denies {}Chronic itching / tearing //allergies/blepharitis

  Denies {}Headache/Scalp tenderness //giant cell arteritis.

<: PAST MEDICAL HISTORY :>

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MEDICAL HISTORY:

//especially DM, HTN, CAD

 - { }

SURGICAL HISTORY:

//especially eye surgeries

 - { }

OCULAR HISTORY:

 - { }

SOCIAL HISTORY:

 - { }

FAMILY HISTORY:

//especially Glaucoma, cataracts, blindness

 - { }

ALLERGIES:

 - { }

CURRENT MEDICATIONS:

//specifically ask about eyedrops

 - { }

<: OBJECTIVE :>

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Vision (corrected)

  od: {}20/20

  os: {}20/20

Pupil

  od: {}5 to 3

  os: {}5 to 3

  {}brisk, {}no APD ou

Pressure

  od: {}15

  os: {}15

Confrontational fields full {}ou

EOMI {}ou

SLIT LAMP EXAM:

  External:      wnl {}ou 

                 {ptosis, proptosis}

                 {pre-auricular, submandibular, or submental lymphadenopathy}

  Lids/Lashes:   wnl {}ou 

                 {blepharitis}

                 {inner lid follicles or papillary bumps}

  Conjuc/Sclera: wnl {}ou, no injection {}ou

                 {injection, reduced with vasoconstrictor drops}

  Cornea:        wnl {}ou

                 {erosions / abrasions}

                 {middle stroma clear}

                 {endothelial folds or guttate bumps}

  Ant. Chamber:  deep and quiet {}ou

                 {red/white cells} {flare}

  Iris:          {}flat, {}round, no neovascularization {}ou

  Lens:          PCIOL {}ou

                 {clear / hazy / cataract}

                 {phakic (have their own lens) / pseudophakic / aphakic}

  Vitreous:      PVD {}ou, no cells {}ou

RETINA:

  Macula:    wnl {}ou: flat good light reflex

  Vessels:   wnl {}ou: no AV nicking, no attenuation of arterioles

  Periphery: wnl {}ou: flat, no tears or holes

  Disk:      wnl {}ou: cup to disk ratio {}0.2, disk pink and healthy

<: ASSESSMENT & PLAN :>

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Assessment:

-- { }

Plan:

-- { }

FOLLOW-UP: 

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