Eyes

{Eyes}

[+] yes, present, positive
[-] no, absent, negative
[~] equivocal
[\] not applicable, not performed
[?] unknown, unsure, unavailable
{ } annotation, comment

PRESENTING COMPLAINTS OR ISSUES
Reasons for visit:
[-] new problem/issue
[-] review/follow-up

Right eye: 
[-] vision change
[-] vision loss
[-] floaters
[-] pain
[-] irritation
[-] itching
[-] redness
[-] discharge
[-] watering
[-] foreign body sensation

Left eye: 
[-] vision change
[-] vision loss
[-] floaters
[-] pain
[-] irritation
[-] itching
[-] redness
[-] discharge
[-] watering
[-] foreign body sensation

History of presenting complaint:
-

Management to date:
-

Diagnostic investigation results:
[+] 
[~] 
[-] 
[?]

History since last contact:
-

PAST MEDICAL HISTORY
Relevant past medical history:
[+] 
[-]

PHYSICAL EXAMINATION
Right eye: 
[-] conjunctival injection
[-] pterygium
[-] discharge
[-] lid swelling
[-] lid mass
[-] blepharitis
[-] ectropion
[-] entropion
[-] ingrowing lashes
[-] conjunctival foreign body
[-] corneal ulcer/abrasion
[-] corneal foreign body
[-] hyphaema

Left eye: 
[-] conjunctival injection
[-] pterygium
[-] discharge
[-] lid swelling
[-] lid mass
[-] blepharitis
[-] ectropion
[-] entropion
[-] ingrowing lashes
[-] conjunctival foreign body
[-] corneal ulcer/abrasion
[-] corneal foreign body
[-] hyphaema

Vision tests:
  visual acuity - distance (Snellen chart): X/6
    uncorrected: 
      right: 
      left: 
    corrected: 
      right: 
      left: 
 
  visual acuity - near (Times Roman card @ 40 cm):
    uncorrected: 
      right: N
      left: N
    corrected: 
      right: N
      left: N
 
  Colour vision (Ishihara plates) errors:

Visual fields (confrontation): {abnormalities}
    [-] right
    [-] left

Pupillary reflexes (light/accommodation): {abnormalities}
    [-] right
    [-] left

Ophthalmoscopy: {abnormalities}
    right eye: 
      [-] cataract
      [-] retinopathy
      [-] abnormal retinal vessels
      [-] papilloedema

left eye: 
      [-] cataract
      [-] retinopathy
      [-] abnormal retinal vessels
      [-] papilloedema

ASSESSMENT
Clinical summary:
[+] 
[~] 
[-]

Diagnosis/es:
1. 
2.

Differential diagnosis:
-

MANAGEMENT PLAN
Procedures performed:
-

Diagnostic investigations requested:
-

Referrals:
-

Information and advice given:
-

Medication:
-

FOLLOW-UP
Outstanding issues:
-

Next appointment:
-

[dqref.com 260131]

Eyes

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