Guest guest Posted May 14, 2003 Report Share Posted May 14, 2003 (A little history first) The patient is monocular. He was referred by an optometrist who noted his vision was described as 'blurry' and that he had a cataract. Examination confirmed a visually significant cataract in his only eye, left. He has had no vision on the right since he was a young child at 2 weeks of age. Apparently an infection destroyed potential for vision in that eye. PHYSICAL EXAMINATION HEAD: Normocephalic. Again, he has (s/l) ticycle (as in bicycle), right eye. ........... ............ .......... OPHTHALMOLOGIC EXAM: Vision in right eye without light perception. Left 20/60 with refraction -0.25, +1.5 axis 170. The left pupil reacts briskly. He has full extraocular movements on the left. Confrontational field is also full. Right eye, again is _______. He has dermatochalasis bilaterally. Slit lamp examination confirms ptisis and an opacified cornea. . There is no view posterior to the cornea. The eye is quiet. The left eye has normal skin and mucosae, clear cornea, deep and quiet chamber and normal iris. There is 3+ nuclear sclerosis of an amber color, 2-3+ cortical changes and 1+ posterior subcapsular cataract. Funduscopic exam on the left shows cup/disk ratio of 0.7 with a thinner temporal rim and poles. The macula is normal. The vessels are 1-2+ attenuated. The peripheral retina is normal. CAN ANYONE HELP ME WITH THIS REPORT? Thanks, Ruth Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 14, 2003 Report Share Posted May 14, 2003 Hi Ruth! I found phthisis in Taber's and Sloane's Medical Word Book (under ophthalmology), meaning a wasting illness, and phthisis bulbi, meaning wasting of ocular tissue. My spellchecker took phthisic and phthisical. Hope that helps! ) Need Ophthalmology Help! (A little history first) The patient is monocular. He was referred by an optometrist who noted his vision was described as 'blurry' and that he had a cataract. Examination confirmed a visually significant cataract in his only eye, left. He has had no vision on the right since he was a young child at 2 weeks of age. Apparently an infection destroyed potential for vision in that eye. PHYSICAL EXAMINATION HEAD: Normocephalic. Again, he has (s/l) ticycle (as in bicycle), right eye. .......... ........... ......... OPHTHALMOLOGIC EXAM: Vision in right eye without light perception. Left 20/60 with refraction -0.25, +1.5 axis 170. The left pupil reacts briskly. He has full extraocular movements on the left. Confrontational field is also full. Right eye, again is _______. He has dermatochalasis bilaterally. Slit lamp examination confirms ptisis and an opacified cornea. . There is no view posterior to the cornea. The eye is quiet. The left eye has normal skin and mucosae, clear cornea, deep and quiet chamber and normal iris. There is 3+ nuclear sclerosis of an amber color, 2-3+ cortical changes and 1+ posterior subcapsular cataract. Funduscopic exam on the left shows cup/disk ratio of 0.7 with a thinner temporal rim and poles. The macula is normal. The vessels are 1-2+ attenuated. The peripheral retina is normal. CAN ANYONE HELP ME WITH THIS REPORT? Thanks, Ruth Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 14, 2003 Report Share Posted May 14, 2003 I've done some digging in my Sted's " eyeball " book, and I'm just not finding anything, sorry. By the way I wanted to point out that apparently depending on your part of the country and your doctors' preference, it would cup/disc ratio, not disk. All the ophthalmologists I've ever worked for wanted disc, not disk, but again, it depends on your docs' preference and apparently where they were trained Jan jantranscribes@... " Typing is my life. " " Whoever signs the paycheck makes the rules. " Need Ophthalmology Help! (A little history first) The patient is monocular. He was referred by an optometrist who noted his vision was described as 'blurry' and that he had a cataract. Examination confirmed a visually significant cataract in his only eye, left. He has had no vision on the right since he was a young child at 2 weeks of age. Apparently an infection destroyed potential for vision in that eye. PHYSICAL EXAMINATION HEAD: Normocephalic. Again, he has (s/l) ticycle (as in bicycle), right eye. ........... ............ .......... OPHTHALMOLOGIC EXAM: Vision in right eye without light perception. Left 20/60 with refraction -0.25, +1.5 axis 170. The left pupil reacts briskly. He has full extraocular movements on the left. Confrontational field is also full. Right eye, again is _______. He has dermatochalasis bilaterally. Slit lamp examination confirms ptisis and an opacified cornea. . There is no view posterior to the cornea. The eye is quiet. The left eye has normal skin and mucosae, clear cornea, deep and quiet chamber and normal iris. There is 3+ nuclear sclerosis of an amber color, 2-3+ cortical changes and 1+ posterior subcapsular cataract. Funduscopic exam on the left shows cup/disk ratio of 0.7 with a thinner temporal rim and poles. The macula is normal. The vessels are 1-2+ attenuated. The peripheral retina is normal. CAN ANYONE HELP ME WITH THIS REPORT? Thanks, Ruth Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 14, 2003 Report Share Posted May 14, 2003 Thanks, . I'll bet that's it! Ruth ================ " , Kaye " wrote: > Hi Ruth! > I found phthisis in Taber's and Sloane's Medical Word Book > (under > ophthalmology), meaning a wasting illness, and phthisis bulbi, > meaning > wasting of ocular tissue. My spellchecker took phthisic and > phthisical. > Hope that helps! ) > > Need Ophthalmology Help! > > > > (A little history first) > The patient is monocular. He was referred by an > optometrist who > noted his vision was described as 'blurry' and that he > had a > cataract. Examination confirmed a visually significant > cataract > > in his only eye, left. He has had no vision on the right > since > he was a young child at 2 weeks of age. Apparently an > infection > destroyed potential for vision in that eye. > > PHYSICAL EXAMINATION > > HEAD: Normocephalic. Again, he has (s/l) ticycle (as in > > bicycle), right eye. > .......... > ........... > ......... > > OPHTHALMOLOGIC EXAM: Vision in right eye without light > perception. Left 20/60 with refraction -0.25, +1.5 axis > 170. > The left pupil reacts briskly. He has full extraocular > movements > on the left. Confrontational field is also full. Right > eye, > again is _______. He has dermatochalasis bilaterally. > Slit > lamp > examination confirms ptisis and an opacified cornea. . > There is > no view posterior to the cornea. The eye is quiet. The > left > eye > has normal skin and mucosae, clear cornea, deep and quiet > > chamber > and normal iris. There is 3+ nuclear sclerosis of an > amber > color, 2-3+ cortical changes and 1+ posterior subcapsular > > cataract. Funduscopic exam on the left shows cup/disk > ratio of > 0.7 with a thinner temporal rim and poles. The macula is > > normal. The vessels are 1-2+ attenuated. The peripheral > retina > is normal. > > > CAN ANYONE HELP ME WITH THIS REPORT? > > Thanks, > > Ruth > > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
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