Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Cataract - Second Opinion

Description: The patient seeks evaluation for a second opinion concerning cataract extraction.
(Medical Transcription Sample Report)

SUBJECTIVE: The patient seeks evaluation for a second opinion concerning cataract extraction. She tells me cataract extraction has been recommended in each eye; however, she is nervous to have surgery. Past ocular surgery history is significant for neurovascular age-related macular degeneration. She states she has had laser four times to the macula on the right and two times to the left, she sees Dr. X for this.

OBJECTIVE: On examination, visual acuity with correction measures 20/400 OU. Manifest refraction does not improve this. There is no afferent pupillary defect. Visual fields are grossly full to hand motions. Intraocular pressure measures 17 mm in each eye. Slit-lamp examination is significant for clear corneas OU. There is early nuclear sclerosis in both eyes. There is a sheet like 1-2+ posterior subcapsular cataract on the left. Dilated examination shows choroidal neovascularization with subretinal heme and blood in both eyes.

ASSESSMENT/PLAN: Advanced neurovascular age-related macular degeneration OU, this is ultimately visually limiting. Cataracts are present in both eyes. I doubt cataract removal will help increase visual acuity; however, I did discuss with the patient, especially in the left, cataract surgery will help Dr. X better visualize the macula for future laser treatment so that her current vision can be maintained. This information was conveyed with the use of a translator.



Keywords: soap / chart / progress notes, advanced neurovascular age-related macular degeneration, neurovascular age, macular degeneration, visual acuity, cataract extraction, neurovascular, degeneration, visual, eyes, macular, cataract,
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