Patient:
DOB:
Contact:
Date of Service:
Initial/Follow up
This is a referred by for consultation regarding:
Has a previous ophthalmic history of:
1. Refractive Error.
The patient has otherwise been in good ophthalmic health. There is no history of cataracts,
glaucoma, strabismus, amblyopia, diplopia, vision loss, positive visual phenomena, external
symptomatology or ocular trauma.
Family History: no significant family ocular history
Social History:
Military History:
PAST MEDICAL HISTORY
Allergies:
Medications:
Operations:
Additional Hospitalizations:
REVIEW OF SYSTEMS
Dermatologic: No history of rash or birth mark
Musculoskeletal: No history of fracture or arthritis
Endocrinologic: No history of thyroid disease or diabetes
Neurologic: No h/o CVA, weakness, numbness, or incoordination
Respiratory: No history of pneumonia or asthma
Cardiovascular: No chest pain, palpitations, orthopnea or DOE
GI: No dysphagia, No h/o of hepatitis, Inflammatory bowel disease, no diarrhea or constipation
GU: No history of UTI, nocturia, or kidney stones
Heme: No history of cancer; No history of anemia or blood transfusion
EXAMINATION:
Oriented x 3
Pain Score: 0
Vision:
OD: 20/
OS: 20/
Near vision:
Wearing:
Manifest:
Color plates:
Titmus:
Visual Fields: Full to confrontation
No red desaturation across vertical or horizontal midlines
Amsler Grid:
EXTERNAL:
Orbit: no obvious asymmetry, no resistance to retropulsion
Conjunctiva: without injection
PF:
Upper Lid Excursion:
CN V: facial sensation intact
CN VII: good orbicularis strength
Hertel:
PUPILS: round, reactive, no afferent pupillary defect
MOTILITY:
Grossly full D/V, normal pursuit and saccades
Normal pursuit at zero velocity
Maddox rod: demonstrates a comitant exodeviation with no significant vertical
Hess Screen:
SLIT LAMP:
OD:
Lids: margins unremarkable
Conj: quiet
Cornea: clear
Chamber: deep and quiet
Iris: unremarkable
Lens: without significant opacity
OS
Lids: margins unremarkable
Conj: quiet
Cornea: clear
Chamber: deep and quiet
Iris: unremarkable
Lens: without significant opacity
TA:
Cycloplegic retinoscopy:
DILATED/UNDILATED FUNDOSCOPY:
Vitreous: View 20/20 OU
C/D: without heme, pallor, or edema, +SVP OU
Vasculature: unremarkable
Maculae: unremarkable
Periphery: normal nondepressed peripheral examination
OCT
Date
Type
Avg Thickness OD/OS
Other Testing
Date
Test
Impression/result
Pertinent Imaging
Date
Test
Impression/result
Impression
IMPRESSION:
1. Refractive error
Ben Ableman, MD
Walter Reed National Military Medical Center