---
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)*