Name:
Elective
Individually Designed Extramural
Course number/name:
Date Patient Seen:
Patient's Age:
Years Months
Patient's Gender:
Male Female
Location:
Clinic ER Home Visit In-Patient Nursing Home Other Out-Patient
Eye:
Right Left Both
Chief Complaint: (to select more than one item, click on each item while holding down the <control> key)
Blurred Vision Diplopia Eye Check Loss of Vision Follow/up *Other
If "other", describe:
Physical Exam:
Primary Diagnosis: (check all that apply)
*None
Disorder of the Eye - Unspecified
ocular histoplasmosis
Age-related Macular Degeneration (ARMD)
drooping eyelids
ocular hypertension
AIDS-related eye disorders
dry eye
allergies of the eye
epiphora
open globe repair
amblyopia
epiretinal membrane (ERM)
angioma
exam under anesthesia
optic ischemic syndrome
anisocoria
exotropia
optic neuritis
aphakia
exposure keratopathy
asthenopia
fuch's dystrophy
astigmatism
fungal keratitis
Bardet-Beidl Syndrome
glasses prescription
orbital tumor
basal cell nevus syndrome
glaucoma
Other Ill-Defined Disorder of Eyes
Batten Disease
Graves disease ophthalmopathy
Pain in/or Around Eyes
Bell’s palsey
heterophobia
photophobia
blepharitis
HIV retinopathy
post-op check
blepharospasm
HSV keratitis
blindness
HTN
branch retinal vein occlusion / central retinal vein occlusion
hyperopia
cancer: eye
hypertensive retinopathy
retinal detachment
cancer: eyelid skin
hypertropia
retinitis pigmentosa
cataract
hyphema
cataract removal
hypopyon
retinopathy of prematurity / myopia
chalazion
immature cataract
ruptured globe
choroidal hemangioma
intraocular lens repositioning
choroidal melanoma
intropion
Sjogren's syndrome
choroidal metastasis
IOL lens OS
choroidal nevus
IOL placement
choroidal osteoma
iritis
closed-angle glaucoma
keratitis
suspected child abuse
CN V palsy
keratoconus
sympathetic ophthalmia
CN IV palsy
lid laceration
temporal arteritis
computer vision syndrome
macular degeneration
conjunctival tumor
macular pucker
conjunctivitis
multiple sclerosis
corneal abrasion
myopia
corneal dystrophy
narrow-angle glaucoma
corneal transplant
neurofibromatosis
corneal ulcers
NFT
vitreous detachment
cystoid macular edema (CME)
NLDO
vitreous hemorrhage
CVA
Normal Eye Exam
Von Hippel’s angioma
dacryocystitis
nystagmus
diabetic check
diabetic retinopathy
Procedure: (to select more than one item, click on each item while holding down the <control> key)
direct ophthalmoscopy indirect ophthalmoscopy slit-lamp exam Angiography Anterior Capsulotomy Argon Laser Photocoagulation Argon Laser Trabeculoplasty A-Scan Astigmatic Keratotomy (AK) Automated Lamellar Keratoplasty (ALK) Bilateral Lateral Rectus Recession Bilateral Medial Rectus Recession Biomicroscopy Blepheroplasty B-Scan Cataract Extraction Cataract Extraction With Intraocular Lens Chalazion Removal Co2 Laser Conjunctival Sampling And Corneal Scraping Corneal Epithelial Debridement. Corneal Implants Corneal Mapping Corneal Topography Corneal Transplant Cpc Cryopexy Destruction Of Lesion Of Retina And Choroid Enucleation Examination With Cycloplegia Or Mydriasis (Dilated Ophthalmology) Excision Of A Pterygium Excision Or Destruction Of Lesion Or Tissue Of Conjunctiva Exophthalmometry Extracapsular Cataract Extraction Fluoroscein Angiography Fundus Photography I&D Incision Of Cornea Intra-Capsular Cataract Extraction (ICCE) Io Recession Io Recession With Transposition Iridectomy Iridoplasty Iridotomy Keratometry Laser Laser Interferometry Lucentis (Or Macugen Or Avastin) Injections Membranectomy Oct Pachymetry Pars Plana Vitrectomy Phacoemulsification Photocoagulation Posterior Capsulotomy Probe And Irrigation Probing Probing And Stent Placement Ptosis Repair - Mueller's Muscle Resection Radial Keratotomy (RK) Removal Of Corneal Sutures. Removal Of Superficial Foreign Bodies. Repair Of Cornea Repair Of Laceration Of Conjunctiva Repair Of Retinal Tear Retained Intraocular Foreign Body Retrieval Of Donor Eyes For Transplantation. Schirmer Test Scleral Buckle Scleral Fistulization Slit Lamp Tear Film Evaluation And Transillumination Superficial Ocular Trauma Surgicial Vision Correction Thermokeratoplasty Trabeculectomy Vitrectomy Yag Iridotomy. *Other
Procedure Role:
None Observed Assisted Performed
Surgeries:
Problem List:
Notes/Comments:
Problems with any entries? Contact Jean Afflerbach