179 lines
5.6 KiB
Markdown
179 lines
5.6 KiB
Markdown
---
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type: eye exam record
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category: eye
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person: Yanxin Lu
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date: 2017-09-14
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provider: Dr. Catherine Park, O.D.
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source: lu_Austin_2017.pdf
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---
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# Eye Exam Record — Yanxin Lu — 09/14/2017
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**Patient:** Lu, Yanxin
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**DOB:** 10/17/1989
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**Electronically signed by:** Dr. Park, Catherine — 09/14/2017
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**Electronic Signature:** Electronically Signed By: Catherine Park O.D. on 09/17/2017 09:05 AM
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---
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## Page 1 of 4
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### Current Glasses Rx
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| | Sphere | Cyl | Axis |
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|----------|--------|-------|------|
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| OD | -5.50 | -0.75 | 047 |
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| OS | -5.25 | -1.00 | 138 |
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| Visual Acuity | OD | OS | OU |
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|---------------|-------|-------|-------|
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| DVA | 20/25 | 20/25 | 20/20 |
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| NVA | | | 20/20 |
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### Current Glasses Rx2
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- DVA:
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- NVA:
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### Auto Refraction
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| | Sphere | Cyl | Axis |
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|----------|--------|-------|------|
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| OD | -5.75 | -1.50 | 031 |
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| OS | -5.50 | -2.00 | 139 |
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- DVA:
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- NVA:
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### Manifest Refraction
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| | Sphere | Cyl | Axis |
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|----------|--------|-------|------|
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| OD | -5.50 | -1.25 | 030 |
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| OS | -5.50 | -1.75 | 145 |
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| Visual Acuity | OD | OS | OU |
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|---------------|-------|-------|-------|
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| DVA | 20/20 | 20/20 | 20/20 |
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| NVA | 20/20 | 20/20 | 20/20 |
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### CL Trial Rx
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*(empty)*
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### IOP
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- **Date/Time:** 9/14/2017 4:25:28 PM
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- **IOP OD:** 10
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- **IOP OS:** 10
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- **Test:** Digital
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### K-Readings
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| Eye | Flat | Axis | Steep | Axis |
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|-----|-------|------|-------|------|
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| OD | 43.00 | 028 | 44.50 | 118 |
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| OS | 43.00 | 155 | 44.50 | 065 |
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### Other Measurements
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- **Dist IPD:** 67.0
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- **Diagnosis Code:** H52.223
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- **Procedure Code:** 92015
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### Rx Summary Table
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| 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 |
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|------|-------|----------|-----------|-------------|---------|--------|--------|----------|-----------|-------------|---------|--------|--------|
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| Presenting Spec Rx | | | -5.50 | -0.75 | 047 | 20/25 | | | -5.25 | -1.00 | 138 | 20/25 | |
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| Auto Refraction | | | -5.75 | -1.50 | 031 | | | | -5.50 | -2.00 | 139 | | |
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| Manifest Refraction | | | -5.50 | -1.25 | 030 | 20/20 | 20/20 | | -5.50 | -1.75 | 145 | 20/20 | 20/20 |
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| Final Spec Rx | Crizal AR | | -5.50 | -1.25 | 030 | 20/20 | 20/20 | | -5.50 | -1.75 | 145 | 20/20 | 20/20 |
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---
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### Reason for Visit
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- **EXAMINATION:** Eye Examination~Glasses examination
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- **Last examination:** 3-4 years ago
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- **OCCUPATION:** Student — Rice University
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### Chief Complaint
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*(listed but no specific complaint text provided)*
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---
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## Page 2 of 4
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### History of Present Illness (HPI)
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HISTORY OF PRESENT ILLNESS: No complaints reported of physical ocular symptoms. Not experiencing routine headaches or double vision. No reports of visual floaters below.
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VISION COMPLAINT: Vision may have changed. Difficulties are not problematic.
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### Patient History
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- **OCULAR HISTORY:** Eye Turn.
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- **MEDICAL HISTORY:** No pertinent past medical history exists.
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- **SYSTEMIC FAMILY HISTORY:** Family medical history is reported to be unremarkable.
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- **OCULAR SURGICAL HISTORY:** No pertinent past ocular surgical history exists.
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- **OCULAR FAMILY HISTORY:** Family ocular history is reported to be unremarkable.
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- **SYSTEMIC MEDICATIONS:** No reported systemic medications. No known systemic medication allergies.
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- **SOCIAL HISTORY:** No reported use of tobacco, alcohol or narcotics.
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### Review of Systems
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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)
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### Vision
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- **PRESENTING SPECTACLE Rx OBSERVATIONS:** RX current gl SV
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- **SUBJECTIVE RESPONSES OBSERVATIONS:** Trial frame confirmed clear and comfortable vision.
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---
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## Page 3 of 4
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### Examination
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- **DILATION ORDERS:** Patient denied dilation. Patient denied Optomap.
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- **CONFRONTATION FIELDS OBSERVATIONS:** Fields were found to be full in all quadrants, OD. Fields were found to be full in all quadrants, OS.
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- **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.
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- **DISPOSITION:** Patient is pleasant and sociable.
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- **ORIENTATION:** Patient is fully alert to time, place and person.
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### Impressions
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- **IMPRESSION/REFRACTION:** Myopia, Astigmatism
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### Plan
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- **PRINTED SPEC Rx:** 09/14/2017 16:52
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- **SPECTACLE PLAN:** Adaptation to Rx expected. Rec AR, impact resistance lenses, UV protection.
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- 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.
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---
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## Page 4 of 4
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### Patient Management
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- **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.
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- **ORDERS:** Schedule on or about: Examination: Annual Eye Examination. Timeline: 120090601.
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### Diagnosis
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- Myopia, bilateral — H52.13
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- Regular astigmatism, bilateral — H52.223
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### Procedure
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- Exam Comp. New
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- Current Tobacco Non-user
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- Exam Refraction New Patient
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### Addendum
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*(empty)*
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