Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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View this sample in Blog format on MedicalTranscriptionSamples.com

Sample Type / Medical Specialty: Ophthalmology
Sample Name: Ophthalmology - Letter - 1

Description: The patient was referred for evaluation of cataracts bilaterally
(Medical Transcription Sample Report)

MM/DD/YYYY


XYZ, O.D.


RE: ABC
DOB: MM/DD/YYYY

Dear Dr. XYZ:

Thank you for your referral of patient ABC. The patient was referred for evaluation of cataracts bilaterally.

On examination, the patient was seeing 20/40 in her right eye and 20/50 in the left eye. Extraocular muscles were intact, visual fields were full to confrontation OU, and applanations are 12 mmHg bilaterally. There is no relative afferent pupillary defect. On slit lamp examination, lids and lashes were within normal limits. The conj is quiet. The cornea shows 1+ guttata bilaterally. The AC is deep and quiet and irises are within normal limits bilaterally. There is a dense 3 to 4+ nuclear sclerotic cataract in each eye. On dilated fundus examination, cup-to-disc ratio is 0.1 OU. The vitreous, macula, vessels, and periphery all appear within normal limits.

Impression: It appears that Ms. ABC' visual decline is caused by bilateral cataracts. She would benefit from having removed. The patient also showed some mild guttata OU indicating possible early Fuchs dystrophy. The patient should do well with cataract surgery and I have recommended this and she agreed to proceed with the first eye here shortly. I will keep you up to date of her progress and any new findings as we perform her surgery in each eye.

Again, thank you for your kind referral of this kind lady and I will be in touch with you.

Sincerely,



Keywords: ophthalmology, extraocular, applanations, slit lamp, visual field, visual, guttata, surgery, cataracts, eye,
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