Medical Record # or DOB
Chief complaint, straightforward.
HPI: XX year old (white, AA, hispanic, etc) (fe)male presents with...
Concentrate on visual symptoms, such as blurry vision? Photophobia? Eye pain? Eye redness? Floaters? Flashes of light? Etc. Intuitively, acute issues require acute attention, so remember to describe when symptoms started, how long they last, etc. Brief but pertinently thorough is the norm. Systemic review of symptoms can be pertinent, especially in cases of uveitis, sometimes a separate ROS is relevant.
POH: no sx, no trauma, no CLs, no strabismus/patching
Past Ocular History. sx = surgery. CLs = contact lenses. Basic ocular history includes previous surgeries and previous traumas to the eyes including severity (ie, required surgery). Contact lens history includes soft versus hard CLs, wearing time, sleeping habits (ie, take them out every night?), cleaning habits (ie, clean every night?), and disposing habits if disposables. Its also important to note any history of strabismus, as patients often recall patching, remember having a "lazy eye", or say an eye hasn't seen well all their life. A story consistent with amblyopia can explain poor vision in an otherwise normal appearing eye and save you grief trying to figure it out.
Past Medical History. Straightforward.
Past Surgical History.
Medications. Drops, as well as systemic medications. Ask separately, patients often forget about drops, and others are in "eye mode" and don't mention pills unless you ask.
SH: no smoke/etoh/drugs
Social History. Standard habits such as smoking, alcohol, and drug use are important, especially mosrt recent use of alcohol and drugs in the trauma setting. Smoking can exacerbate certain eye disease (ex, thyroid). Occupational history is also important especially in trauma, but also when determining the impact of poor vision on daily life (ie, cataract evaluation). Uveitis and infectious etiologies benefit from a sexual history and travel history.
Family history. Concentrate on eyes specifically, but systemic disease is also helpful.
VA sc: 20/100, 20/70
cc: 20/20, 20/20
Visual acuity. sc = without correction. cc = with correction. Right eye first. Vision is reported with the following Snellen system, listed in decreasing levels of acuity:
20/20 down to 20/400
CF @ XX ft: Count fingers, typically in inches or feet. Ability to count your fingers at said distance, test by holding up different number of fingers.
HM @ XX ft: Hand Motions, typically in inches or feet. Ability to see your hand moving at said distance, test by using side to side motions, and also up and down motions to see if patient can distinguish direction.
LP: Light perception. Ability to tell if the light is on, or off. Can also add projection if directional ability intact.
NLP: No light perception. Cannot distinguish anything from the eye. Total blindness.
Note that sometimes patients don't know English letters, especially the pediatric population. In these cases, one can use the HOTV chart, by giving a near card with the letters H, O, T, and V on it and allowing the patient to match. Or, by using the Allen chart (picture chart).
WRx: -3.00sph, -2.50+0.25x180
Wearing prescription, ie, prescription of glasses the patient is wearing.
MRx: -3.25sph => 20/20
-2.25+0.50x180 => 20/20
Manifest refraction, ie, what you measure the prescription as, and the resultant acuity. Don't forget to test acuity.
CRx: -3.00sph => 20/20
-2.50+0.25x180 => 20/20
Cycloglegic refraction, refraction after cycloplegia. Typically used in pediatric patients, not done for adults except in special cases. In children, cycloplegia is typically accomplished by administering cyclogyl (cyclopentolate) 1%, in addition to the usual mydriacyl (tropicamide) 1% and phenylephrine 2.5%. The idea is to remove accomodation and its effects on the refraction. Cycloplegic refraction is done 30 minutes after the drops are administered, and so is not done until a majority of the below exam is completed. Its usually written in this part of the exam form simply to group all the vision data together.
ARx: -2.75sph, -2.00sph
Autorefraction. Refraction by automated machine. Can be helpful to guide the manifest, to make sure you're in ballpark range, or help get a difficult refraction started at a reasonable point.
NRx: +2.50sph => J1, +2.50sph => J2
Near refraction. Near vision can be reported in a few ways, often the Jaeger system is used. Simply detect the lowest line appreciated on the near card, and record the J level as indicated on the card. Can also record in the 20/20 (Snellen) system as indicated on the card.
P: 4-2 no APD, 4-2 no APD
Pupils. Dark pupil size - bright light pupil size, presence of Afferent Pupillary Defect (also written as RAPD, Relative APD). ALWAYS check pupils before dilating. Used to assess optic nerve function or diffuse retinal disease, a small APD can also be present in amblyopia. Check pupils with a bright light, such as Finhoff or even the indirect head lamp. Rated as no APD, or 1+ to 4+ APD (4+ is amaurotic pupil that does not react to light).
EOM full OU
ExtraOcular Motions. Right eye is written first (leftmost), with the directions represented as if you were standing behind the page and looking out (ie, right temporal direction is leftmost). There are a number of ways EOM can be represented. Sometimes the notation "motility" is used. A normal exam can be remarked as above "full OU", or by drawing the cardinal directions blank as above, with a "0" at each direction, or with a "100%" at each direction. Deficits can be drawn with -1 - -4 in the direction of deficit, or with a rating 0 - 100%.
CVF: full OU
Confrontational Visual Fields. Right eye is written first, with the fields represented as if you were standing behind the page and looking out (ie, right temporal field is leftmost). Normal can be written as "full OU" as above, or drawn with checks as above. Deficits usually noted by shading on a plus diagram like above.
Hertel's: 22, 21 @ 103
Exophthalmometry using the Hertel's instrument. Right eye measurement, left eye measurement @ base. Used to measure proptosis, only needed if indicated (ie, trauma, orbital floor fracture, thyroid, etc).
Ishihara's: 11/11, 10/11
Ishihara color plates. Number seen correctly by right eye over total plates, number seen correctly by left eye over total plates. Not used in every exam, rather used typically in two general situations: pediatrics to screen for colorblindness and to assess optic nerve function. For efficiency purposes, usually only the plates with numbers on them are used from the Ishihara's, so usually the result is taken from 11 total plates. An alternative when the color plates are not available is the "red desat", reported as "red desat: 100%, 75%", where the first number is red saturation detected by right eye, second number is red saturation detected by left eye. This is a subjective test using a red colored bottle cap, where the patient rates the "redness" of the cap, comparing the two eyes. In the example above, the patient would have responded that the right eye saw a normal red cap, while the left eye seemed to see only a "75% red" cap, indicating possibly optic nerve compromise on the left.
Ta: 15, 17 @ 12:24pm
Tonometry by Applanation. Right eye pressure, left eye pressure @ time of measurement. Intraocular pressure (IOP) can be measured by applanation, pneumotonometry (written Tp), or Tonopen (tricky, sometimes written as Tp also, better to write out pen or something equivalent). Always record the method the pressure was taken, since there is some variation in accuracy, and don't forget to always note the time.
External: WNL WNL
External exam. WNL = within normal limits. Can often be represented with a drawing of the lids and externa as needed, especially with trauma, or external lesions.
SLE: OD OS
Slit Lamp Exam. When words can't describe it, draw it and give its dimensions, or grade it from 1+ to 4+.
L/L: WNL WNL
Lids/Lashes. WNL = within normal limits. The most common finding to see here is MGD, Meibomian Gland Dysfunction, indicating plugging of the Meibomian glands along the lids margins, graded. Can often draw lesions as in external exam.
C/S: W&Q W&Q
Conjunctiva/Sclera. W&Q = white and quiet. Most commonly will see 1+ conj inj, conjunctival injection, graded. Can also see scleral inj or episceral inj. Another common term is SCH, subconjunctival hemorrhage. Chemosis swelling of the conjunctiva, can be bloody or non-bloody.
K: clr clr
Cornea. Clr = clear. Drawn as a circle. Commonly will see: PEE punctate epithelial erosions. Some people synonomously use the term SPK, superficial punctate keratopathy, but the Cornea service will point out that this is incorrect and specific to Thygeson's SPK, and so better to stick with PEE. K lac corneal laceration. Epi defect epithelial defect, reported with dimensions of lesion. MCE mycrocystic edema, refers to epithelial edema. DF Descemet's folds, common with diffuse corneal edema.
Uveitic signs on the cornea include KP keratic precipitates, on the endothelium which can be small, medium, large, and granulomatous (mutton fat) or non-granulomatous. Can also see pigment dusting or very small deposits of pigment on the endothelium. A ring drawn circumferentially inside the corneal circle can represent a graft (ie, penetrating keratoplasty PK meaning corneal transplant), or could be a LASIK flap if there is a superior or nasal area not drawn in (ie, the hinge of the LASIK flap).
AC: D&Q D&Q
Anterior chamber. D&Q = deep and quiet. The most common abnormal findings are flare and cell: 1+F/2+C.
Flare is assessed by how brightly you can "see" the highest intensity light beam in the AC, and represents proteinaceous and other material in the AC reflecting the light beam, like "seeing" movie light beam in a theater. Rated as tr (trace), 1+ to 4+.
Cell is the number of cells you can appreciate in a 1mm highest intensity light beam. They can be remarked as pigmented, or more commonly white cells. They are rated as: rare, occasional, then 1+ to 4+. The Uveitis service does not like to use the word "trace" when referring to cells.
The alternative to deep is shallow when referring to AC depth.
I: RR RR
Iris. RR = round and reactive. Want to remark on NVI (neovascularization of the iris) in diabetic patients, specifically point out no NVI to show you looked. May note transillumination defects, cysts, nevi, etc. Can also note uveitic nodules, ie, Busacca nodules on the surface of the iris, and Koeppe nodules at the pupillary margin.
L: clr clr
Lens. Clr = clear. There are 3 more common forms of lens changes:
NS: nuclear sclerosis.
ACC: anterior cortical changes.
PSC: posterior subscapsular cataract.
Can draw pecularities to lens opacities as well.
AV: no cell no cell
Anterior vitreous. Not always commented upon, but relevant when there is uveitis or certain other disease states. Typically report the presence/absence of cells, white or pigmented (ie, Schaeffer's sign, also called "tobacco dust", which is pigmented cells in the AV after retinal detachment).
DFE M1 N2.5 @ 12:30pm:
Dilated fundus examination. M1 = mydriacyl 1%, N2.5 = phenylephrine 2.5%. Good form to note which drops administered to dilate, in peds usually add in C1 or cyclogyl 1%. Typically, before dilating, make sure you've: checked vision, checked pupils, checked pressure, and checked anterior chamber depth (don't typically want to dilate someone with a shallow chamber as you may precipitate angle closure).
C/D: 0.3x0.4 sharp, healthy rim 0.3x0.35 sharp, healthy rim
Cup to Disc Ratio. From 0.1 to 1.0. Often best to DRAW the nerves. Often written simply as 0.3, to mean the cup size is 0.3 of the disc size. More specific notation, particularly in Glaucoma, given as 0.3x0.35 to note both horizontal and vertical cup size separately. Mention of the appearance and health of the nerve is recommended, will often see the word pallor, graded up to 4+, which can be sectoral or diffusely involving the whole disc.
D/M/V/P: WNL WNL
Retinal exam, typically drawn. D/M/V/P = Disc/Macula/Vessels/Periphery. Some common retinal abbreviations are: CSME = clinically significant macular edema, a diabetes specific term. NVD = neovascularization of the disc. NVE = neovascularization elsewhere (ie, not involving the disc). CME = cystoid macular edema. RD = retinal detachment. RRD = rhegmatogenous retinal detachment. TRD = tractional retinal detachment. Sometimes the inner aspect of the retinal drawing will have semicircles drawn along it, that lookslike lace. This refers to SD = scleral depressed exam, which is used to look at the far periphery of the retina. WWP = white without pressure, sometimes the periphery can have a whitish appearance usually caused by the vitreous base, which can look like the same whitening you get when you do scleral depression only there is no "pressure" or depression being applied.
Assessment and Plan. Some use Impression and Plan, some group it together, some like to number them separately. Like a regular medical note, only generally very brief and to the point.
FANG - Fluorescein angiography, used to assess the retinal vasculature
OCT - Optical Coherence Tomography, for disc or macula analysis
B Scan - ultrasound of the eye, generally used when there is anterior segment opacity, with no view to the retina
Ct or CCT or Pachy - Pachymetry, measurement of corneal thickness used commonly for glaucoma patients as well as corneal disease