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 - 4

Description: The patient is being referred for evaluation of diabetic retinopathy.
(Medical Transcription Sample Report)

MM/DD/YYYY

XYZ, M.D.

RE: ABC
DOB: MM/DD/YYYY

Dear Dr. XYZ:

Thank you for your kind referral for patient ABC. The patient is being referred for evaluation of diabetic retinopathy. The patient was just diagnosed with diabetes; however, he does not have any serious visual complaints at this time.

On examination, the patient is seeing 20/40 OD pinholing to 20/20. The vision in the left eye is 20/20 uncorrected. Applanation pressures are normal at 17 mmHg bilaterally. Visual fields are full to count fingers OU and there is no relative afferent pupillary defect. Slit lamp examination was within normal limits, other than trace to 1+ nuclear sclerosis OU. On dilated examination, the patient shows a normal cup-to-disc ratio that is symmetric bilaterally. The macula, vessels, and periphery are also within normal limits.

In conclusion, Mr. ABC does not show any evidence of diabetic retinopathy at this time. We recommended him to have his eyes dilated once a year. I have advised him to follow up with you for his regular check-ups. Again, thank you for your kind referral of Mr. ABC and we should check on him once a year at this time.

Sincerely,



Keywords: ophthalmology, pupillary defect, cup-to-disc ratio, cup-to-disc, evaluation of diabetic retinopathy, referred for evaluation, diabetic retinopathy, visual, dilated, retinopathy, examination, diabetic,
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