眼科英文病历的( 眼科检查).pdf

Sample History and Physical Note Charting Plus? - Electronic Medical Records Note for John Doe on 6/6/02 - Chart 1124 Chief Complaint: This 26 year old male presents today for a complete eye examination. Allergies: Patient admits allergies to aspirin resulting in disorientation, GI upset. Medication History: Patient is currently taking amoxicillin-clavulanate 125 mg-31.25 mg tablet, chewable medication was prescribed by A. General Practitioner MD, Adrenocot 0.5 mg tablet medication was prescribed by A. General Practitioner MD, Vioxx 12.5 mg tablet (BID). PMH: Past medical history is unremarkable. Past Surgical History: Patient admits past surgical history of (+) appendectomy in 1989. Social History: Patient denies alcohol use. Patient denies illegal drug use. Patient denies STD history. Patient denies tobacco use. Family History: Unremarkable. Review of Systems: Eyes: (-) dry eyes (-) eye or vision problems (-) blurred vision Constitutional Symptoms: (-) constitutional symptoms such as fever, headache, nausea, dizziness Musculoskeletal: (-) joint or musculoskeletal symptoms Eye Exam: Patient is a pleasant, 26 year old male in no apparent distress who looks his given age, is well developed and nourished with good attention to hygiene and body habitus. Visual Acuity: Visual acuity - uncorrected: OD: 20/10 OS: 20/10 OU: 20/15 Refraction: Lenses - final: OD: +0.50 +1.50 X 125 Prism 1.75 OS: +6.00 +3.50 X 125 Prism 4.00 BASE IN Fresnel Add: OD: +1.00 OS: +1.00 OU: Far VA 20/25 Pupils: Pupil exam reveals round and equally reactive to light and accommodation. Motility: Ocular motility exam reveals gross orthotropia with full ductions and versions bilateral. Visual Fields: Confrontation VF exam reveals full to finger confrontation OU.