DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Loss of vision in left eye.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic woman who was transferred from an outside hospital where she was admitted with blurry vision. The patient stated that she was at work, and over a few hours, she lost vision in her left eye. She could not drive. She had difficulty walking. Prior to that, she was having some itching in her eyes for the last one week. She was taking Flonase. The patient's friend took her to the hospital where she had to help her walk. The patient was transferred here for further evaluation. The patient complained of generalized body ache since yesterday. She denied any fever. The patient denied any weakness, numbness in her arms and legs. She never had these symptoms ever before. There is no family history of multiple sclerosis. The patient denied any rash. She is under stress as her mother is in the hospital with cancer of the lungs. The patient is able to take care of herself.
PAST MEDICAL HISTORY: Gastric ulcer.
PAST SURGICAL HISTORY: None.
SOCIAL HISTORY: The patient lives with a roommate. She denied any smoking and alcohol use.
MEDICATION: Afrin and Percocet.
FAMILY HISTORY: Cancer.
PHYSICAL EXAMINATION:
GENERAL: The patient is lying in bed, crying in pain.
HEENT: Normal.
NECK: Supple.
LUNGS: Clear.
HEART: S1 and S2 normal.
NEUROLOGIC: Alert and oriented x2. Speech was normal. Affect: The patient was constantly crying. Cranial nerve examination: The patient had 2 mm dilated pupils, slowly reactive. Extraocular movements are intact. She could not count fingers from her left eye. She had light perception. She could not recognize the color, and on the right side, she could count fingers. Rest of the cranial nerve examination was normal. Motor examination was very difficult to do, as the patient was in extreme pain. She was extremely tender to touch all over. Reflexes, 2+ knees, 1+ ankle reflexes, downgoing toes. Sensory examination was grossly intact. Coordination: Gait was not checked due to severe pain.
ASSESSMENT: This is a (XX)-year-old Hispanic woman who was admitted to the hospital with loss of vision in the left eye. The patient's neurological examination revealed loss of vision in her left eye to light perception only. Differential diagnosis includes optic neuritis, but we cannot explain the patient's generalized pain. We would also keep local eye disease like central retinal artery occlusion in our differential even though we do not think that is the case in her. Generalized pain is of unclear etiology. She is under stress. An MRI of the brain and orbit was normal. Sedimentation rate is 20.
PLAN:
1. Visual evoked potentials. If the patient has evidence of optic neuritis, we will start her on IV steroids.
2. Pain control.
3. Ophthalmology consultation.
4. Motrin.
Thank you, Dr. Doe, for giving us the opportunity to evaluate this pleasant patient.
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REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Loss of vision in left eye.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic woman who was transferred from an outside hospital where she was admitted with blurry vision. The patient stated that she was at work, and over a few hours, she lost vision in her left eye. She could not drive. She had difficulty walking. Prior to that, she was having some itching in her eyes for the last one week. She was taking Flonase. The patient's friend took her to the hospital where she had to help her walk. The patient was transferred here for further evaluation. The patient complained of generalized body ache since yesterday. She denied any fever. The patient denied any weakness, numbness in her arms and legs. She never had these symptoms ever before. There is no family history of multiple sclerosis. The patient denied any rash. She is under stress as her mother is in the hospital with cancer of the lungs. The patient is able to take care of herself.
PAST MEDICAL HISTORY: Gastric ulcer.
PAST SURGICAL HISTORY: None.
SOCIAL HISTORY: The patient lives with a roommate. She denied any smoking and alcohol use.
MEDICATION: Afrin and Percocet.
FAMILY HISTORY: Cancer.
PHYSICAL EXAMINATION:
GENERAL: The patient is lying in bed, crying in pain.
HEENT: Normal.
NECK: Supple.
LUNGS: Clear.
HEART: S1 and S2 normal.
NEUROLOGIC: Alert and oriented x2. Speech was normal. Affect: The patient was constantly crying. Cranial nerve examination: The patient had 2 mm dilated pupils, slowly reactive. Extraocular movements are intact. She could not count fingers from her left eye. She had light perception. She could not recognize the color, and on the right side, she could count fingers. Rest of the cranial nerve examination was normal. Motor examination was very difficult to do, as the patient was in extreme pain. She was extremely tender to touch all over. Reflexes, 2+ knees, 1+ ankle reflexes, downgoing toes. Sensory examination was grossly intact. Coordination: Gait was not checked due to severe pain.
ASSESSMENT: This is a (XX)-year-old Hispanic woman who was admitted to the hospital with loss of vision in the left eye. The patient's neurological examination revealed loss of vision in her left eye to light perception only. Differential diagnosis includes optic neuritis, but we cannot explain the patient's generalized pain. We would also keep local eye disease like central retinal artery occlusion in our differential even though we do not think that is the case in her. Generalized pain is of unclear etiology. She is under stress. An MRI of the brain and orbit was normal. Sedimentation rate is 20.
PLAN:
1. Visual evoked potentials. If the patient has evidence of optic neuritis, we will start her on IV steroids.
2. Pain control.
3. Ophthalmology consultation.
4. Motrin.
Thank you, Dr. Doe, for giving us the opportunity to evaluate this pleasant patient.
Ophthalmology SOAP Note Samples Ophthalmology Operative Sample Reports
Ophthalmology Operative/Surgical Example Reports
Medical Transcription Word Seeker - Google Search for MTs - Searches just Medical Websites
