眼科英文病历( 眼科检查)

3．这是裂隙灯，检查眼睛的时候会有比较强的光照射眼睛，请坚持一会儿。

向前看，向上看，向下看，眨眨眼。

眼睛有慢性结膜炎（角膜炎，倒睫，结石，滤泡，乳头，角膜异物）。

This is slit-lamp. It will send strong light on your eyes. Keep your eyes open, please. Look straight, look up, look down, and blink your eyes. You have chronic conjunctivitis (keratitis, trichiasis, ［］concretion, follicle, papilla, cornea foreign body). you should see an eye doctor. 4．您眼睛有没有如下症状：闪光、有漂浮物、光晕、复视、时常或严重的头痛，眼痛、眼红、流泪或沙砾感？Do you have any of these problems with your eyes: flashes of light, floaters, halos around lights, double vision, frequent or severe headaches,eye pain, redness, tearing, or a gritty feeling in your eyes?5．症状从什么时候开始的？一般持续多长时间？When did this happen? How long has it lasted?6．您曾经检查过眼睛吗？有没有做过手术、受过外伤或严重的感染？Have you ever had any medical examinations of your eyes? Any surgeries, injuries, or serious infections of your eyes? 7．您曾经用过眼药吗？若有，什么药，您服用了多长时间，它用来治疗什么病，剂量如何？Have you ever used any medication for your eyes? What medication have you used? How long have you been taking the medication, what is it for, and what is the dosage?8．您的眼睛现在发炎了，目前不适宜配戴隐形眼镜，请去眼科检查治疗，痊愈后才能继续配戴隐形眼镜。

眼科门诊病历书写范文病历书写范文模板：
门诊病历
就诊日期：
病人基本信息：
姓名：
性别：
年龄：
科别：
就诊号：
主要症状：
现病史：
既往史：
体格检查：
实验室检查：
初步诊断：
治疗方案：
医生签名：
病历书写范文：
门诊病历
就诊日期：2022年2月14日
病人基本信息：
姓名：***
性别：男
年龄：40岁
科别：眼科
就诊号：20220214001
主要症状：双眼视力模糊，眼睛干涩刺痛
现病史：患者近期双眼视力不清，尤其是近距离看物体模糊，同时伴有眼睛干涩和刺痛的感觉。

无眼外伤及眼红、流泪、结膜充血等症状。

既往史：无明显眼部疾病，无眼科手术史。

体格检查：一般情况良好，双眼裸眼视力分别为左眼0.3，右眼0.4。

眼睑无明显异常，结膜轻度充血，无明显分泌物，角膜清晰，房角开放，晶体透明，眼压正常。

实验室检查：暂无
初步诊断：双眼屈光不正，干眼症
治疗方案：建议配戴适度近视矫正眼镜，同时使用人工泪液缓解干眼症状，定期复诊进一步监测病情。

医生签名：（医生签名）。

姓名年龄岁科别眼科病室床号床住院号开始终结日期时间处方者执行者执行时间长期医嘱日期时间处方者执行者执行时间眼科护理常规三级护理普通饮食冲洗双眼结膜囊bid0.25%氯霉素眼液点双眼qid眼白内障术后护理常规二级护理普通饮食裂隙灯检查qd检眼镜检查qd测眼压qd测视力qd前房深度测量qd冲洗双眼结膜囊bid妥布霉素地塞米松眼液点眼qid托吡卡胺滴眼液点眼bid琥乙红霉素片0.25g tid肾上腺色腙片5mg tid贝诺酯片0.5g tid第 1 页姓名年龄岁科别眼科病室床号床住院号开始终结日期时间处方者执行者执行时间长期医嘱日期时间处方者执行者执行时间第 2 页姓名年龄岁科别眼科病室床号床住院号月日时分处方者临时医嘱执行者执行时间全血分析血凝检查尿液分析肝功肾功血脂血糖乙肝两对半梅毒螺旋体抗体丙型肝炎抗体人类免疫缺陷病毒抗体胸片心电图泪道冲洗裂隙灯检查检眼镜检查测眼压测视力前房深度测量色觉检查眼位、眼球运动检查双眼FVEP、FERG、30°视野眼角膜曲率、内皮细胞计数眼A、B超，人工晶状体度数姓名年龄岁科别眼科病室床号床住院号月日时分处方者临时医嘱执行者执行时间拟定于明日在局麻下行眼白内障超声乳化、进口折叠型人工晶状体植入术术前冲洗术眼结膜囊术前用复方托吡卡胺滴眼液散大术眼瞳孔直径约8mm2%利多卡因注射液5ml 术中备用绵阳万江眼科医院眼科入院病历（一）X片号：科别：眼科病室：病床：住院号：CT号：姓名：性别：年龄：岁职业：婚姻：婚民族：族籍贯：省市（县）现住址或单位：联系电话：入院日期：年月日时记录日期：年月日时病史叙述者：患者病史主诉：现病史：病员入院无明确诱因出现无眼红痛不适今日到我院求治，门诊以“”收入我科。

自病后，病员精神、饮食及睡眠良好，大小便正常。

病史记录内容真实准确，病人（或委托人）签字：年月日既往史：既往健康状况：良好一般√较差（疾病：）外伤史：无传染病史：无手术史：无药物过敏史：无输血史：无预防接种史：无个人史：嗜烟：无√有（支/日年）嗜酒：无√有（ml/日年）其他：无婚姻史：婚；配偶身体状况：月经及生育史：无此项√月经（岁来潮；持续时间：天；周期：天；末次月经）生育：子女数：—家族史：同类病史：无体格检查Ｔ：℃Ｐ：次／分Ｒ：次／分ＢＰ：/ｍｍＨｇ一般情况：发育（良好中等√不良）营养（良好中等√不良）神志：清晰皮肤粘膜：无黄染淋巴结：未扪及淋巴结肿大头面部：头颅：无畸形耳：外耳道无疖肿鼻：通气畅口腔：无溃疡扁桃体：无肿大咽喉：无充血颈部：外形：对称气管：居中甲状腺：未扪及肿大血管：未见异常搏动胸部：肺脏：双肺未闻及干湿啰音。

眼科标准英文病历( 眼科检查)Charting Plus? - Electronic Medical Sample History and Physical Note RecordsNote for John Doe on 6/6/02 - Chart 1124Chief Complaint: This 26 year old male presents today for a complete eye examination.Allergies: Patient admits allergies to aspirin resulting in disorientation, GI upset. Medication History: Patient is currentlytaking amoxicillin-clavulanate 125 mg-31.25 mg tablet, chewable medication was prescribed by A. General Practitioner MD, Adrenocot 0.5 mg tablet medication was prescribed by A. General Practitioner MD, Vioxx 12.5 mg tablet (BID). PMH: Past medical history is unremarkable.Past Surgical History: Patient admits past surgical history of (+) appendectomy in 1989. Social History: Patient denies alcohol use.Patient denies illegal drug use. Patient denies STD history. Patient denies tobacco use.Family History: Unremarkable.Review of Systems: Eyes: (-) dry eyes (-) eye or vision problems (-) blurred vision ConstitutionalSymptoms: (-) constitutional symptoms such as fever, headache, nausea, dizziness Musculoskeletal:(-) joint or musculoskeletal symptomsEye Exam: Patient is a pleasant, 26 year old male in no apparent distress who looks his given age, is well developed and nourished with good attention to hygiene and body habitus. Visual Acuity: Visual acuity - uncorrected: OD: 20/10 OS: 20/10 OU: 20/15Refraction:Lenses - final:OD: +0.50 +1.50 X 125 Prism 1.75OS: +6.00 +3.50 X 125 Prism 4.00 BASE IN FresnelAdd: OD: +1.00 OS: +1.00OU: Far VA 20/25Pupils: Pupil exam reveals round and equally reactive to light and accommodation. Motility: Ocular motility exam reveals gross orthotropia with full ductions and versions bilateral. Visual Fields: Confrontation VF exam reveals full to finger confrontation OU.IOP: IOP Method: applanation tonometry OD: 10 mmHg Medications: Alphagan; 0.2% Condition: improving.Keratometry:OD: K1 35.875K2 35.875OS: K1 35.875K2 41.875Lids/Orbit: Bilateral eyes reveal normal position without infection. Bilateral eyelids reveals white and quiet.Slit Lamp: Corneal epithelium is intact with normal tear film and without stain. Stroma is clear and avascular. Corneal endothelium is smooth and of normal appearance.Anterior Segment: Bilateral anterior chambers reveal no cells orflare with deep chamber.Lens: Bilateral lenses reveals transparent lens that is in normal position. Posterior Segment: Posterior segment was dilated bilateral. Bilateral retinas reveal normal color, contour, and cupping.Retina: Bilateral retinas reveals flat with normal vasculature outto the far periphery. Bilateral retinas reveal normal reflex and color.Test Results: No tests to report at this timeImpression: Eye and vision exam normal.Plan: Return to clinic in 12 month(s).Patient Instructions:Patient was given verbal and written instructions regarding eye care following pupil dilation.__________________________________ Dr. An. Ophthalmologist, MDCharting Plus? - Electronic Sample Referral LetterMedical Records6/6/02Marcus Welby, M.D. th1231 8 Street, Suite 222West Des Moines, IA 50265Dear Dr. Welby:John Doe was seen in my office in consultation as requested by youas a new patient for evaluation and care. The following is a summary of my findings and recommendations:Impression: Eye and vision exam normal.Plan: Return to clinic in 12 month(s).If I may be of any further assistance in the care of your patient, please let me know. Thank you for providing me the opportunity to participate in the care of your patients.Sincerely,An. Ophthalmologist, MDCharting Plus? - Electronic Sample Prescription Medical RecordsDr. An. Ophthalmologist, MDDEA#:_________________________________________________________Name: John J Doe Date: 6/6/02OD: +0.50 +1.50 X 125 Prism 1.75OS: +6.00 +3.50 X 125 Prism 4.00 BASE IN FresnelAdd: OD: +1.00 OS: +1.00Dr._____________________________________________Charting Plus? - Electronic Sample Billing Statement Medical Records Billing Statement - Thursday, June 06, 2002Provider: An. Ophthalmologist, MDPatient: John J Doe, Chart 1124123 E. Freckle St.Jersey City, NJ 07040Diagnoses1. V72.0 Examination Of Eyes And VisionTreatments1. 99213 Office or other outpatient visit - est. patient - 15 min.Related Diagnoses: V72.0Modifiers:Units:Referring Physician: A. General Practitioner, MDDate Last Seen: 07/26/2001Charting Plus? - Electronic Medical Sample Patient Instructions RecordsPatient Instructions for John Doe on 6/6/02YOUR EYES HAVE BEEN DILATEDDilation drops temporarily increase the size of your pupils. This lets us accurately investigatethe health of your eyes and other important general health aspects. Dilation of your eyes is atemporary inconvenience; however, benefits far outweigh the inconvenience.The effects of eye dilation drops will gradually decrease. It typically takes TWO to SIX HOURS for the effects to wear off. During this time, reading may be more difficult andsensitivity to light may increase. For a short time, wearing sunglasses may help. Notify usif you feel your long distance vision is blurred excessively before attempting to drive. Your patience during this very important procedure is appreciated!CALL MY OFFICE IMMEDIATELY AT 515-327-8850 IF YOU EXPERIENCE EXCESSIVE PAIN, DISCOMFORT OR NAUSEAREMEMBER TO HAVE REGULAR MEDICAL EYE EXAMINATIONS.Eye disease can occur at any age. Since most blindness is preventable if diagnosed andtreated early, it is extremely important to have regular eye examinations. Keep in mind thatmany eye diseases are asymptomatic until after the damage to the eye has already occurred so early detection is the key. Use this as a reminder to plan for regular eye examinations to maintain sight throughout a lifetime._______________________________An. Ophthalmologist, MDCATARACTWhat is a cataract?* A cataract is the loss of transparency of the lens of the eye. It often appears like awindow that is fogged with steam.What causes cataract formation?* Aging, the most common cause.* Family history.* Steroid use.* Injury to the eye.* Diabetes.* Previous eye surgery.* Long-term exposure to sunlight.How do I know if I have a cataract?* The best way for early detection is regular eye examinations by your medical eye doctor.There are many causes of visual loss in addition to the cataract such as problems involvingthe optic nerve and retina. If these other problems exist, cataract removal may not result inthe return or improvement of vision. Your eye doctor can tell you how much improvement in vision is likely.Does it take a long time for a cataract to form?* Cataract development varies greatly between patients and is affected by the cause of the cataract. Generally, cataracts progress gradually over many years. Some people,especially diabetics and younger patients, may find that cataract formation progresses rapidly over a few months making it impossible to know exactly how long it will take for the cataract todevelop.What is the treatment for cataracts?* The only way to remove a cataract is surgery. If the symptoms are not restricting youractivity, a change of glasses may alleviate the symptoms at this time. No medications, exercise, optical devices or dietary supplements have been shown to stop the progression or prevent cataracts.It is important to provide protection from excessive sunlight. Making sure that the sunglassesyou wear screen out ultraviolet (UV) light rays or your regular eyeglasses are coated with aclear, anti-UV coating will help prevent or slow the progression of cataracts.How do I know if I need surgery?* Surgery is considered when your vision is interfering with your daily activities. It is important to evaluate if you can see to do your job and drive safely. Can you read and watchTV in comfort? Are you able to cook, do your shopping and yard work or take your medications without difficulty? Depending on how you feel your vision is affecting your dailylife, you and your eye doctor will decide together when it is the appropriate time to do surgery.What is involved with cataract surgery?* This surgery is generally performed under local anesthesia on an outpatient basis. With the assistance of a microscope, the cloudy lens is removed and replaced with a permanent intraocular lens implant.Right after the surgery you should be able to immediately performall your normal activities except for the most strenuous ones. You will need to take eye drops as directed by your eyedoctor. Follow-up visits are necessary to make sure the surgicalsite is healing withoutproblems.This procedure is performed on over 1.4 million people each year in the United States alone,95% without complications. With this highly successful procedure, 90% of the time visionimproves unless a problem also exists with the cornea, retina or optic nerve. As with any surgery, a good result cannot be guaranteed._______________________________ An. Ophthalmologist, MD。