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眼科英文病历(眼科检查).pdf

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SampleHistoryandPhysicalNoteChartingPlus™-ElectronicMedicalRecords www.medinotes.com NoteforJohnDoeon6/6/02-Chart1124 ChiefComplaint:This26yearoldmalepresentstodayforacompleteeyeexamination. Allergies:Patientadmitsallergiestoaspirinresultingindisorientation,GIupset. MedicationHistory:Patientiscurrentlytakingamoxicillin-clavulanate125mg-31.25mgtablet, chewablemedicationwasprescribedbyA.GeneralPractitionerMD,Adrenocot0.5mgtablet medicationwasprescribedbyA.GeneralPractitionerMD,Vioxx12.5mgtablet(BID). PMH:Pastmedicalhistoryisunremarkable. PastSurgicalHistory:Patientadmitspastsurgicalhistoryof(+)appendectomyin1989. SocialHistory:Patientdeniesalcoholuse.Patientdeniesillegaldruguse.PatientdeniesSTD history.Patientdeniestobaccouse. FamilyHistory:Unremarkable. ReviewofSystems:Eyes:(-)dryeyes(-)eyeorvisionproblems(-)blurredvisionConstitutional Symptoms:(-)constitutionalsymptomssuchasfever,headache,nausea,dizzinessMusculoskeletal: (-)jointormusculoskeletalsymptoms EyeExam:Patientisapleasant,26yearoldmaleinnoapparentdistresswholookshisgivenage,is welldevelopedandnourishedwithgoodattentiontohygieneandbodyhabitus. VisualAcuity: Visualacuity-uncorrected:OD:20/10OS:20/10OU:20/15 Refraction: Lenses-final: OD:+0.50+1.50X125Prism1.75 OS:+6.00+3.50X125Prism4.00BASEINFresnel Add:OD:+1.00OS:+1.00 OU:FarVA20/25 Pupils:Pupilexamrevealsroundandequallyreactivetolightandaccommodation. Motility:Ocularmotilityexamrevealsgrossorthotropiawithfullductionsandversionsbilateral. VisualFields:ConfrontationVFexamrevealsfulltofingerconfrontationOU. IOP:IOPMethod:applanationtonometryOD:10mmHgMedications:Alphagan;0.2%Condition: improving. Keratometry: OD:K135.875K235.875 OS:K135.875K241.875 Lids/Orbit:Bilateraleyesrevealnormalpositionwithoutinfection.Bilateraleyelidsrevealswhiteand quiet. SlitLamp:Cornealepitheliumisintactwithnormaltearfilmandwithoutstain.Stromaisclearand avascular.Cornealendotheliumissmoothandofnormalappearance. AnteriorSegment:Bilateralanteriorchambersrevealnocellsorflarewithde