Transcribed Medical Transcription Sample Reports and Examples
MT HelpLine Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Ophthalmology

Ophthalmology is the branch of medicine which deals with the anatomy, physiology and diseases of the eye.



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Decreased Vision Consult
One-week history of decreased vision in the left eye. Past ocular history includes cataract extraction with lens implants in both eyes.

Difficulty Distance Vision & Fine Print at Near
Difficulty with both distance vision and with fine print at near.

Diplopia
He awoke one morning and had double vision. He states when he closed each eye, the double vision dissipated. The double vision entirely dissipated within one hour. The next day he woke up and he had double vision again.

Electronystagmogram
Abnormal electronystagmogram demonstrating prominent nystagmus on position testing in the head hanging right position.

Eye Examination - H&P
Complete eye examination - Normal eye and vision exam.

Eyelid Squamous Cell Carcinoma Excision
Excision of right upper eyelid squamous cell carcinoma with frozen section and full-thickness skin grafting from the opposite eyelid.

Intraocular Lens Implant
Secondary scleral suture fixated posterior chamber intraocular lens implant with penetrating keratoplasty. A concurrent vitrectomy and endolaser was performed by the vitreoretinal team.

Lid Laceration Repair
Repair of upper lid canalicular laceration - Sample/Template.

Midface Lift & Blepharoplasty
Endoscopic subperiosteal midface lift using the endotine midface suspension device. Transconjunctival lower lid blepharoplasty with removal of a portion of the medial and middle fat pad.

Nasolacrimal Probing
Bilateral nasolacrimal probing. Tearing, eyelash encrustation with probable tear duct obstruction bilateral. Distal nasolacrimal duct stenosis with obstruction, left and right eye

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NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples