dc66e42ec4
Categories now match folder names (15 canonical values). Types normalized to 25 canonical values per VAULT_MAP.md spec. Context-aware mapping: W-2s→tax-form, lease files→lease, vet records→vet, etc.
5.6 KiB
5.6 KiB
type, category, person, date, provider, source
| type | category | person | date | provider | source |
|---|---|---|---|---|---|
| lab-results | medical | Yanxin Lu | 2017-09-14 | Dr. Catherine Park, O.D. | 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.
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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.
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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)