__/29/_____ John Doe
#00-00-7
SUBJECTIVE: Six-month periodic intraocular pressure check
for ocular hypertension. Patient has not scheduled consultation for
cataract and capsulotomy.
OBJECTIVE: Slit-lamp Examination - Lids, lashes, adnexa,
conjunctiva, cornea, and iris are clear OU. The anterior chamber is deep and quiet. Angles are 4
temporally.
Scleral spur with four-mirror gonioscopy OU. Lens shows nuclear
and cortical cataract OD. Intraocular lens is centered OS. 2+ capsular
fibrosis OS.
ASSESSMENT: 1) Ocular hypertension with reassuring
intraocular pressures today. 2) Cataract OD. 3) Pseudophakia
with after cataract extreme vision OS.
PLAN: 1) Cataract consultation/laser capsulotomy
consultation scheduled with Wolfe Clinic. 2) Return to the clinic postoperatively for
follow-up OD.
__________, O.D./ht:___
__/02/____
______________ #00-00-19-9
SUBJECTIVE: The patient is a ten-year-old female with
complaint of headaches, one to two per week, when reading, frontally. Patient
reports headache duration of approximately thirty minutes, Tylenol does help
with relief.
FAMILY HISTORY of esophoria in patient's older sister.
OBJECTIVE: Cover test is 2-4 esophoria at distance and
near. Extraocular motilities are smooth and full. Visual fields are
full to confrontation. Pupils are equal, round, and reactive to
light.
Negative afferent pupillary defect. Slit-lamp Examination - Lids, lashes,
conjunctiva, cornea, iris, and lens are all clear. The anterior
chamber is clear and quiet. Angles are 4 temporally. Internal with
dilation, cup-to-disk is 0.5 and 0.6. The posterior pole and macula are clear with
a positive foveal light reflex. The periphery is clear to past equator
OU.
ASSESSMENT: 1) Hyperopia. 2) Esophoria. 3) Ocular health no apparent pathology. 4) Headaches
likely related to uncorrected hyperopia.
PLAN: 1) Subjective prescription given. Recommend
initially wearing for near and gradually building up to full-time wear. 2)
Discussed at length with patient and patient's mother the benefits of
correction due to symptoms and relation to findings today. 3) Vision
examination in one year.
___________, O.D./ht:____
__/09/____ John Doe
#0-00-74-0
SUBJECTIVE: The patient is a 71-year-old male with history
of glaucomatous optic nerve head cupping and no family history of
glaucoma.
Patient currently takes daily antioxidant multivitamins for dry
age-related macular degeneration. History of choroidal nevus OD. HISTORY and REVIEW
OF SYSTEMS are updated in the chart. Current spectacles are one year old.
OBJECTIVE: Patient is oriented times three and in a good
mood. Cover
test is orthophoric at distance. Extraocular motilities are smooth and
full. Visual
fields are full to confrontation. Pupils are equal, round, and reactive to
light.
Negative afferent pupillary defect. Slit-lamp Examination - Lids, lashes, adnexa
dermatochalasis OU.
Conjunctiva, cornea, and iris are clear. The anterior chamber is clear and
quiet. Angles
are 4 temporally.
Lens shows 1+ nuclear sclerosis and 2+ cortical cataract OD, 1+ nuclear
sclerosis and cortical cataract OS. Cup-to-disk is 0.7 and 0.6. The posterior pole
is clear.
Macula shows 1+ drusen and pigment irregularity OU, otherwise posterior
pole is clear.
Peripheral retina shows choroidal nevus 2.5 disk diameters by 2.5 disk
diameters, flat. The periphery is clear to past equator otherwise OU.
ASSESSMENT: 1) Myopia, astigmatism, and presbyopia. 2) Cataract. 3)
Choroidal nevus OD, stable. 4) Dry age-related macular
degeneration.
5) Large optic nerve head cup with reassuring intraocular pressures and
history of normal visual fields. No family history of glaucoma.
PLAN: 1) No change in prescription. 2) Continue
antioxidant multivitamin with lutein daily. Discussed benefits of dark, leafy, green
vegetables and ultraviolet protection. 3) Return to the clinic in one year.
________, O.D./ht:____
__/08/____ Jane Doe
#00-00-00-8
SUBJECTIVE: Follow-up for keratitis OS. Patient reports
improvement in symptoms. Compliance with TobraDex every two hours OS
and Polysporin at bedtime. She reports no redness or photophobia, mild
irritation only.
OBJECTIVE: Anterior segment of the right eye is
clear. Left
eye, 0.5 mm infiltrate superiorly is less dense today. Epithelium is
intact. There
is 1+ superficial punctate keratitis diffusely OS. The anterior
chamber is deep and quiet.
ASSESSMENT: 1) Resolving keratitis and secondary anterior
uveitis. 2)
Medicamentosa OS.
PLAN: 1) Discontinue Polysporin ointment. 2) Taper TobraDex
over the next three days and then discontinue. Gradually restart contact lens wear and
rebuild wearing time. 3) Return to the clinic in seven to ten days
for comprehensive examination or follow-up sooner per symptoms.
____________, O.D./ht:___
__/22/_____ Jane Doe
#00-00-00
SUBJECTIVE: The patient is a 64-year-old female
complaining of difficulties with near detail vision. Current spectacles
are one year old.
History of dry eyes and use of Artificial Tears p.r.n. No complain of
diplopia.
OBJECTIVE: Patient is oriented times three and in a
good
mood. Cover test shows
to 6-8 right esotropia at distance. Extraocular motilities are smooth and
full. Visual
fields are full to confrontation. Pupils are equal, round, and reactive to
light.
Negative afferent pupillary defect. Slit-lamp Examination - Lids, lashes,
adnexa, conjunctiva, cornea, and iris are clear. The anterior
chamber is clear and quiet. Angles are 4 temporally. Lens shows 1+
nuclear sclerosis and cortical changes OU. Internal with dilation, cup-to-disk is 0.6
and 0.4. The
posterior pole shows subtle pigment irregularity with indirect
illumination.
Macula is clear with no foveal light reflex present. Periphery shows
reticular pigment changes OU as before.
ASSESSMENT: 1) Dry eyes currently well-treated with
Artificial Tears p.r.n. 2) Early cataract. 3) Retinal pigment
epithelium changes of peripheral and posterior retina. 4) Hyperopia,
astigmatism, and presbyopia, refractive status is stable. 5) Right esotropia
with previous esophoria at distance, no complaints of diplopia.
PLAN: 1) No change in prescription. 2) Continue
Artificial Tears.
3) Recommend daily antioxidant multivitamin with lutein. Discussed benefits
of dark, leafy, green vegetables and ultraviolet protection. 4) Return to the
clinic in one year for examination.
_________, O.D./ht:___
__/16/____ Jane Doe
#00-00-00-2
SUBJECTIVE: The patient is a 45-year-old female with
history of conventional soft daily-wear contact lens use. Patient reports
unsatisfactory comfort with current lenses. Current spectacles are satisfactory. HISTORY and REVIEW
OF SYSTEMS are updated in the chart.
OBJECTIVE: Cover test is orthophoric at distance. Extraocular
motilities are smooth and full. Visual fields are full to
confrontation.
Pupils are equal, round, and reactive to light. Negative afferent
pupillary defect.
Slit-lamp Examination - Lids, lashes, conjunctiva, cornea, iris, and
lens are all clear.
The anterior chamber is clear and quiet. Angles are 4 temporally. Internal with
direct, cup-to-disk is 0.8 OU. The posterior pole and macula are clear with a
positive foveal light reflex. With Ciba-Focus monthly trial lenses - good
centration, movement and lag OU.
ASSESSMENT: 1) Myopia, prepresbyopia. 2) Large optic
nerve head cup with reassuring intraocular pressures and no family history of
glaucoma. 3)
Good contact lens fit, vision, and comfort with Ciba-Focus monthly lenses.
PLAN: 1) No change in spectacle prescription. 2) Sample of
Opti-Free Express solutions given, gradually rebuild wearing time of
contacts. 3)
Return to the clinic in one week for contact lens check and dilation.
_________,
O.D./ht:___________
__/05/____ Jane Doe
#00-00-32-5
SUBJECTIVE: Four-month follow-up for intraocular pressure
check. Patient takes glaucoma medications, Cosopt and Alphagan b.i.d. OU. She reports
compliance.
She reports also difficulty spacing drops out 10-15 minutes. No vision changes
reported.
OBJECTIVE: Pupils are equal, round, and reactive to
light.
Negative afferent pupillary defect. Slit-lamp Examination - Lids, lashes, adnexa
dermatochalasis OU.
Conjunctiva, cornea, and iris are clear. The anterior chamber is clear and
quiet.
Cataract changes OU as before. Four-mirror gonioscopy reveals scleral spur
OU. No
transillumination defects of the iris.
ASSESSMENT: 1) Chronic open-angle glaucoma. 2) Goal
intraocular pressure of 21 not met with current therapy.
PLAN: 1) Continue Cosopt and Alphagan b.i.d. OU. 2) Discussed with
patient importance of 10-20 minute separation between drops in the morning and
in the evening.
Also recommended three minutes of lid closure after instillation. 3) Return to the
clinic in one month for intraocular pressure check.
__________, O.D./ht:___
__/04/____ John Doe
#00-00-00-4
SUBJECTIVE: Contact lens check. Patient reports
mild vision complaint and dryness with left lens only.
OBJECTIVE: Good centration and movement of lenses OU. Lag is excessive
OD in upgaze, acceptable OS. Conjunctiva and cornea are clear and quiet
OU. With
Acuvue toric trial lenses - good centration, movement and lag OU. Visual acuity is
20/20 OU in the distance.
ASSESSMENT: Patient is not satisfied with Bausch &
Lomb Soflens 66 Toric comfort and vision.
PLAN: 1) Try Acuvue Toric. 2) Return to the clinic in one week.
_____________, O.D./ht:____
__/23/____ Jane Doe
#00-00-05-8
SUBJECTIVE: Contact lens check. Patient reports
good comfort and vision with Acuvue 2 lenses.
OBJECTIVE: Good centration, movement and lag OU. Conjunctiva and
cornea are clear and quiet OU.
ASSESSMENT: Good contact lens fit, vision, and comfort.
PLAN: 1) Prescribe daily-wear two-week disposable. 2) Rebate given
for near supply order here. Provide copy for patient with order in the
near future.
3) Return to the clinic in one year for examination.
____________, O.D./ht:__
__/09/____ Jane Doe
#00-00-00-0
(cc: Tom Jones, M.D., Hackensack Regional Office)
SUBJECTIVE: Two-month follow-up for branch retinal vein
occlusion OS.
Patient is here today to rule out macular edema and
neovascularization.
No symptoms of flashes or floaters reported. Vision is
stable.
Patient was seen by primary care physician one week ago. No problems were
found at that time per patient. In the past patient has had hypertensive
retinopathy and is currently on Coumadin.
OBJECTIVE: Cover test is orthophoric at distance. Extraocular
motilities are smooth and full. Visual fields are full to
confrontation.
Pupils are equal, round, and reactive to light. Negative afferent
pupillary defect.
Slit-lamp Examination - Lids, lashes, adnexa, conjunctiva, cornea, and
iris are clear. The anterior chamber is deep and quiet. Lens shows 2+
nuclear sclerosis and 1+ cortical cataract OU. Posterior vitreous detachment
bilaterally.
The periphery is clear to past equator OU. The posterior pole
of the right eye is clear. Left eye shows cotton-wool spots forming in
area of large retinal hemorrhage superior to optic nerve head. There is no
neovascularization.
Macula is flat and nonedematous OU with mild pigment changes consistent
with previous examinations.
ASSESSMENT: Branch retinal vein occlusion OS.
PLAN: 1) Follow-up here p.r.n. if vision changes are noted
OS. 2)
Reviewed symptoms of retinal detachment. 3) Return to the clinic in two months for
examination with dilation.
__________, O.D./ht:___
__/__/____ Jane Doe
#00-00-31-7
SUBJECTIVE: The patient is a 21-year-old female wanting
new glasses. History of successful contact lens wear. Patient reports
noncompliance with regular monthly replacements. Patient is unsure
of age of current contact lens pair. HISTORY and REVIEW OF SYSTEMS are updated in
the chart.
OBJECTIVE: Cover test is orthophoric at distance and 6
exophoria at near. Extraocular motilities are smooth and full. Visual fields are
full to confrontation. Pupils are equal, round, and reactive to
light.
Negative afferent pupillary defect. Slit-lamp Examination - Lids,
lashes, adnexa, conjunctiva, cornea, iris, and lens are all clear. The anterior
chamber is clear and quiet. Angles are 4 temporally. 1 mm of limbal
neovascularization superiorly OD as before. Good centration, movement and lag OU of
contacts. 3+
deposits OD and 1+ OS. Internal with dilation, cup-to-disk is 0.7 x 0.6 in the
vertical OD, 0.7 x 0.5 in the vertical OS. The posterior pole and macula are clear with
a positive foveal light reflex. The periphery is clear to past equator
OU.
ASSESSMENT: 1) High myopia and astigmatism. 2) Poor compliance
with monthly replacement of contacts. Good fit with current lenses. 3) Corneal
neovascularization OD, stable.
PLAN: 1) Subjective prescription given. 2) Contact lens
parameters updated.
Stressed to patient importance of daily-wear one-month replacement,
recommending Opti-Free Express solutions. 3) Return to the clinic in two years for
examination or follow-up sooner per symptoms.
_________, O.D./ht:___
__/__/______ Jim Doe
#0-0-0-6
SUBJECTIVE: three-week follow-up for posterior vitreous
detachment.
Patient reports less noticeable symptoms regarding flashes and
floaters. No
vision changes reported.
OBJECTIVE: Pupils are equal, round, and reactive to
light.
Negative afferent pupillary defect. Visual fields are full to
confrontation.
Slit-lamp Examination - Lids, lashes, adnexa, conjunctiva, cornea,
iris, and lens are all clear. The anterior chamber is clear and
quiet. Angles
are 4 temporally.
Anterior vitreous is clear OU. Internal with dilation, disk, macula, and
vessels are clear OU. Posterior vitreous detachment OS. Media
clear OD. The
periphery is clear to past equator OU. No holes, breaks, or tears.
ASSESSMENT: Posterior vitreous detachment, stable for
three weeks.
PLAN: 1) Reviewed symptoms of retinal detachment. 2) Return to the
clinic in three months for dilation.
____________, O.D./ht:___
__/__/____ Janey Doe #00-00-02-0
SUBJECTIVE: Contact lens check and dilation. Patient reports
satisfactory comfort and vision with Acuvue 2 lens OD and Bausch & Lomb
Soflens 66 Toric lens OS. Patient reports adaptation to comfort with
current lenses.
OBJECTIVE: Good centration, movement and lag OU, 20o malorientation OS. Conjunctiva and cornea are clear and quiet
OU. Internal
with dilation, cup-to-disk is 0.4 and 0.5. The posterior pole and macula are clear with
a positive foveal light reflex. The periphery is clear to past equator
OU.
ASSESSMENT: 1) Good contact lens fit, vision, and
comfort. 2)
Ocular health no apparent pathology.
PLAN: 1) Prescribe daily-wear two-week disposable,
parameters in chart.
20o malorientation figured into
prescription of left lens. 2) Return to the clinic in one year for
examination.
__________, O.D./ht:___
Contact for Service and
Pricing: 
