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documents/medical/eye/lu_Austin_2017.md

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+---
+type: eye exam record
+category: eye
+person: Yanxin Lu
+date: 2017-09-14
+provider: Dr. Catherine Park, O.D.
+source: lu_Austin_2017.pdf
+---
+
+# Eye Exam Record — Yanxin Lu — 09/14/2017
+
+**Patient:** Lu, Yanxin
+**DOB:** 10/17/1989
+**Electronically signed by:** Dr. Park, Catherine — 09/14/2017
+**Electronic Signature:** Electronically Signed By: Catherine Park O.D. on 09/17/2017 09:05 AM
+
+---
+
+## Page 1 of 4
+
+### Current Glasses Rx
+
+|          | Sphere | Cyl   | Axis |
+|----------|--------|-------|------|
+| OD       | -5.50  | -0.75 | 047  |
+| OS       | -5.25  | -1.00 | 138  |
+
+| Visual Acuity | OD    | OS    | OU    |
+|---------------|-------|-------|-------|
+| DVA           | 20/25 | 20/25 | 20/20 |
+| NVA           |       |       | 20/20 |
+
+### Current Glasses Rx2
+
+- DVA:
+- NVA:
+
+### Auto Refraction
+
+|          | Sphere | Cyl   | Axis |
+|----------|--------|-------|------|
+| OD       | -5.75  | -1.50 | 031  |
+| OS       | -5.50  | -2.00 | 139  |
+
+- DVA:
+- NVA:
+
+### Manifest Refraction
+
+|          | Sphere | Cyl   | Axis |
+|----------|--------|-------|------|
+| OD       | -5.50  | -1.25 | 030  |
+| OS       | -5.50  | -1.75 | 145  |
+
+| Visual Acuity | OD    | OS    | OU    |
+|---------------|-------|-------|-------|
+| DVA           | 20/20 | 20/20 | 20/20 |
+| NVA           | 20/20 | 20/20 | 20/20 |
+
+### CL Trial Rx
+
+*(empty)*
+
+### IOP
+
+- **Date/Time:** 9/14/2017 4:25:28 PM
+- **IOP OD:** 10
+- **IOP OS:** 10
+- **Test:** Digital
+
+### K-Readings
+
+| Eye | Flat  | Axis | Steep | Axis |
+|-----|-------|------|-------|------|
+| OD  | 43.00 | 028  | 44.50 | 118  |
+| OS  | 43.00 | 155  | 44.50 | 065  |
+
+### Other Measurements
+
+- **Dist IPD:** 67.0
+- **Diagnosis Code:** H52.223
+- **Procedure Code:** 92015
+
+### Rx Summary Table
+
+| Type | Notes | Brand OD | Sphere OD | Cylinder OD | Axis OD | DVA OD | NVA OD | Brand OS | Sphere OS | Cylinder OS | Axis OS | DVA OS | NVA OS |
+|------|-------|----------|-----------|-------------|---------|--------|--------|----------|-----------|-------------|---------|--------|--------|
+| Presenting Spec Rx | | | -5.50 | -0.75 | 047 | 20/25 | | | -5.25 | -1.00 | 138 | 20/25 | |
+| Auto Refraction | | | -5.75 | -1.50 | 031 | | | | -5.50 | -2.00 | 139 | | |
+| Manifest Refraction | | | -5.50 | -1.25 | 030 | 20/20 | 20/20 | | -5.50 | -1.75 | 145 | 20/20 | 20/20 |
+| Final Spec Rx | Crizal AR | | -5.50 | -1.25 | 030 | 20/20 | 20/20 | | -5.50 | -1.75 | 145 | 20/20 | 20/20 |
+
+---
+
+### Reason for Visit
+
+- **EXAMINATION:** Eye Examination~Glasses examination
+- **Last examination:** 3-4 years ago
+- **OCCUPATION:** Student — Rice University
+
+### Chief Complaint
+
+*(listed but no specific complaint text provided)*
+
+---
+
+## Page 2 of 4
+
+### History of Present Illness (HPI)
+
+HISTORY OF PRESENT ILLNESS: No complaints reported of physical ocular symptoms. Not experiencing routine headaches or double vision. No reports of visual floaters below.
+
+VISION COMPLAINT: Vision may have changed. Difficulties are not problematic.
+
+### Patient History
+
+- **OCULAR HISTORY:** Eye Turn.
+- **MEDICAL HISTORY:** No pertinent past medical history exists.
+- **SYSTEMIC FAMILY HISTORY:** Family medical history is reported to be unremarkable.
+- **OCULAR SURGICAL HISTORY:** No pertinent past ocular surgical history exists.
+- **OCULAR FAMILY HISTORY:** Family ocular history is reported to be unremarkable.
+- **SYSTEMIC MEDICATIONS:** No reported systemic medications. No known systemic medication allergies.
+- **SOCIAL HISTORY:** No reported use of tobacco, alcohol or narcotics.
+
+### Review of Systems
+
+REVIEW OF SYSTEMS: No reported disorders or current medical treatment of: Allergy, Cardiovascular, Constitutional, Ears/nose/mouth/throat, Endocrine, Gastrointestinal, Immunologic, Integumentary/Skin, Musculoskeletal, Neurologic, Psychiatric, Respiratory (Unless noted otherwise above)
+
+### Vision
+
+- **PRESENTING SPECTACLE Rx OBSERVATIONS:** RX current gl SV
+- **SUBJECTIVE RESPONSES OBSERVATIONS:** Trial frame confirmed clear and comfortable vision.
+
+---
+
+## Page 3 of 4
+
+### Examination
+
+- **DILATION ORDERS:** Patient denied dilation. Patient denied Optomap.
+- **CONFRONTATION FIELDS OBSERVATIONS:** Fields were found to be full in all quadrants, OD. Fields were found to be full in all quadrants, OS.
+- **POSTERIOR SEGMENT:** Vitreous body clear for age and fully attached. Nerve head well perfused, with good rim tissue. Healthy macula with no edema or degenerative changes. Unless otherwise noted below.
+- **DISPOSITION:** Patient is pleasant and sociable.
+- **ORIENTATION:** Patient is fully alert to time, place and person.
+
+### Impressions
+
+- **IMPRESSION/REFRACTION:** Myopia, Astigmatism
+
+### Plan
+
+- **PRINTED SPEC Rx:** 09/14/2017 16:52
+- **SPECTACLE PLAN:** Adaptation to Rx expected. Rec AR, impact resistance lenses, UV protection.
+- Current spec Rx from China. Gave full Rx today (seemed ok with the increase using trial frame). Discussed prism and dem'd in office with LL prism. Pt noticed prism helped.
+
+---
+
+## Page 4 of 4
+
+### Patient Management
+
+- **COUNSELING / EDUCATION:** Patient has been advised to return to clinic ASAP if experiencing any of the following eye symptoms: redness, pain, discharge or vision loss. Importance of dilation as well as the side effects of dilation. I have verbally discussed my clinical findings and recommendations in detail with this patient. The patient does to call or RTC for any concerns and/or questions.
+- **ORDERS:** Schedule on or about: Examination: Annual Eye Examination. Timeline: 120090601.
+
+### Diagnosis
+
+- Myopia, bilateral — H52.13
+- Regular astigmatism, bilateral — H52.223
+
+### Procedure
+
+- Exam Comp. New
+- Current Tobacco Non-user
+- Exam Refraction New Patient
+
+### Addendum
+
+*(empty)*