Sample Type / Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Cataract Extraction Followup
Patient follows up for cataract extraction with lens implant 2 weeks ago. Recovering well from her cataract operation in the right eye with residual corneal swelling, which should resolve in the next 2 to 3 weeks.
(Medical Transcription Sample Report)
Ms. ABC follows up for cataract extraction with lens implant 2 weeks ago. She reports that the right operated eye is improving with its comfort and visual acuity. She reports today a 4-day history of pain and photophobia in the left eye, which is the unoperated eye.
Her past medical history includes insulin requiring diabetes mellitus for the past 28 years. She also has a history of gastritis and currently is being evaluated for inflammatory bowel disease. She is scheduled to see a gastroenterologist in the near future. She is taking Econopred 8 times a day to the right eye and Nevanac, OD, three times a day. She is allergic to penicillin.
The visual acuity today was 20/50, pinholing, no improvement in the right eye. In the left eye, the visual acuity was 20/80, pinholing, no improvement. The intraocular pressure was 14, OD and 9, OS. Anterior segment exam shows normal lids, OU. The conjunctiva is quiet in the right eye. In the left eye, she has an area of sectoral scleral hyperemia superonasally in the left eye. The cornea on the right eye shows a paracentral area of mild corneal edema. In the left eye, cornea is clear. Anterior chamber in the right eye shows trace cell. In the left eye, the anterior chamber is deep and quiet. She has a posterior chamber intraocular lens, well centered and in sulcus of the left eye. The lens in the left eye shows 3+ nuclear sclerosis. Vitreous is clear in both eyes. The optic nerves appear healthy in color and normal in size with cup-to-disc ratio of approximately 0.48. The maculae are flat in both eyes. The retinal periphery is flat in both eyes.
Ms. ABC is recovering well from her cataract operation in the right eye with residual corneal swelling, which should resolve in the next 2 to 3 weeks. She will continue her current drops. In the left eye, she has an area of what appears to be sectoral scleritis. I did a comprehensive review of systems today and she reports no changes in her pulmonary, dermatologic, neurologic, gastroenterologic or musculoskeletal systems. She is, however, being evaluated for inflammatory bowel disease. The mild scleritis in the left eye may be a manifestation of this. We will notify her gastroenterologist of this possibility of scleritis and will start Ms. ABC on a course of indomethacin 25 mg by mouth two times a day. I will see her again in one week. She will check with her primary physician prior to starting the Indocin.
soap / chart / progress notes, visual acuity, photophobia, lens implant, cataract extraction, eye, cataract, corneal,
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