SUBJECTIVE: The patient was seen in followup today. She is a pleasant (XX)-year-old with a history of moderate dry macular degeneration. The patient reports some slight blurring of vision at near.
OBJECTIVE: Visual acuity, uncorrected, is 20/30-2 OD, 20/50 pinhole, 20/40 OS. Intraocular pressure is 19 mmHg OU. Anterior segment examination shows 2+ NS, OD and a PCIOL OS. Dilated funduscopic examination reveals macular drusen, OU. There is a large drusenoid pigment epithelial detachment in the left eye. There is no evidence of any macular edema, hemorrhage or subretinal fluid.
ASSESSMENT AND PLAN: Moderate dry macular degeneration, both eyes, with drusenoid pigment epithelial detachment, left eye. The patient appears stable from a retinal standpoint. We do not see any evidence of choroidal neovascularization, macular edema or hemorrhage. We did review signs and symptoms of these, and she does know to call immediately if she does have any distortion or vision changes. We have asked her to return in six months for a followup.
Ophthalmology SOAP Note Sample #2
SUBJECTIVE: The patient is a pleasant (XX)-year-old who has experienced blurry vision in both eyes, left eye greater than the right eye, for the last several months. Her past ocular history is significant for dry macular degeneration and history of cataract surgeries in both eyes. The patient has also been treated for ocular hypertension.
OBJECTIVE: On examination, the patient’s vision is 20/40 in the right eye and 20/30 in the left eye. Anterior segment examination reveals posterior chamber intraocular lenses in both eyes. Intraocular pressures are 20 in each eye. Fundus examination of the right eye shows the retina to be attached 360 degrees without any tears or holes. There are drusen in the macula. There is a small pocket of subretinal fluid temporal to the optic disc, not involving the fovea. There is no cystoid macular edema present. There is no retinal hemorrhage or lipid exudation present. Fundus examination of the left eye shows the retina to be attached 360 degrees without any tears or holes. There is a flat choroidal nevus inferotemporally. There are RPE changes and drusen in the macula and temporal to the optic disc. There are two distinct pockets of subretinal fluid, one involving the inferior macula and the other one in a juxtapapillary position involving the superonasal portion of the macula. There is no retinal hemorrhage present. There is no cystoid macular edema or lipid exudation present. Fluorescein angiography reveals focal areas of leakage in both eyes consistent with central serous retinopathy. ICG videoangiography shows enlarged and hyperpermeable choroidal vessels in both eyes consistent with central serous retinopathy. There is no tuft of neovascularization noted per ICG angiography.
ASSESSMENT AND PLAN: The patient has pockets of subretinal fluid with pinpoint areas of leakage in both eyes and ICG angiographic pattern consistent with central serous retinopathy. The patient informed us that she is taking Advair for her asthma. Steroid products have been associated with CSR. We asked her to follow up with her primary care physician in order to see whether she could be on a nonsteroidal medicine. We plan to see her back in one month for reevaluation.
Ophthalmology SOAP Note Sample #3
SUBJECTIVE: The patient is a pleasant (XX)-year-old who was noted to have choroidal nevus in her right eye and is here today for further evaluation. She has not experienced loss of vision or distortion.
OBJECTIVE: On examination, her vision is 20/20 in both eyes. Pressures are 15 in each eye. Fundus examination of the right eye reveals an approximately 1 mm flat choroidal nevus temporal to the optic disc. There is no orange pigment or subretinal fluid present. Fundus examination of the left eye shows the retina to be attached 360 degrees without any tears or holes.
ASSESSMENT AND PLAN: The patient has a flat choroidal nevus in her right eye. We reassured her that we do not see any high-risk features. At this point, we recommend annual monitoring. Baseline fundus photographs were obtained today.
SUBJECTIVE: The patient was seen for followup examination. We have been following this patient for epiretinal membrane in his left eye and retinal microaneurysms and hemorrhages in both eyes. We initiated systemic workup, including hemoglobin A1c. The patient’s hemoglobin A1c level came back borderline high. The patient states that his vision has been stable.
OBJECTIVE: On examination, the patient’s vision is 20/60 in the right eye and 20/40 in the left eye. Anterior segment examination reveals posterior chamber intraocular lenses in both eyes. The intraocular pressures are 16 in each eye. Fundus examination showed scattered microaneurysms and intraretinal hemorrhages. There is a stable epiretinal membrane in the left eye. OCT examination showed epiretinal membrane with mild macular edema in the left eye.
ASSESSMENT AND PLAN:
1. Retinal microaneurysms and hemorrhages: The patient’s hemoglobin A1c was borderline high. We asked him to follow up with his primary care physician to be evaluated further for diabetes. We plan to see him back in three months for reevaluation.
2. Epiretinal membranes in the left eye: This appears to be stable. We asked him to continue Acular eye drops three times a day in that eye.
Ophthalmology SOAP Note Sample #5
SUBJECTIVE: The patient was seen for followup examination. The patient has been followed for proliferative diabetic retinopathy and epiretinal membrane. The patient states that her blood sugar is under good control, and she has not noted any loss of vision.
OBJECTIVE: On examination, the patient’s vision was 20/25 in the right eye and 20/30 in the left eye. Intraocular pressures were 16 in the right and 17 in the left. There was no neovascularization of iris. Fundus examination showed PRP laser in both eyes. There was no clinically significant macular edema present. There was epiretinal membrane present in both eyes. OCT examination of the right eye showed no macular edema. OCT examination of the left eye showed less macular edema.
ASSESSMENT AND PLAN: We reassured the patient that she is stable from a retinal standpoint. We asked her to stop Acular eye drops in her right eye and continue Acular in her left eye once a day. We also asked her to continue good control of her blood sugar levels.
Ophthalmology SOAP Note Sample #6
SUBJECTIVE: The patient was seen for followup examination. We have been following him for nonproliferative diabetic retinopathy. He states that his blood sugar is under good control and has not experienced loss of vision.
OBJECTIVE: On examination, the patient’s vision is 20/20 in both eyes. Anterior segment examination is unremarkable. Fundus examination shows scattered dot-blot hemorrhages and microaneurysms in both eyes. There is no clinically significant macular edema in both eyes. There is no neovascularization process present in either eye. OCT examination confirms a lack of macular edema in both eyes. Fluorescein angiography shows microaneurysms with minimal leakage without any neovascularization process in either eye.
ASSESSMENT AND PLAN: The patient has mild to moderate nonproliferative diabetic retinopathy. We asked him to continue good control of his blood sugar and pressure levels. We will continue regular monitoring.
Ophthalmology SOAP Note Sample #7
SUBJECTIVE: The patient was seen for followup examination. We have been following her for epiretinal membrane in her right eye and extramacular drusen in both eyes. She states that her vision has been stable.
OBJECTIVE: On examination, the patient’s vision is 20/25 in the right eye and 20/20 in the left eye. Anterior segment examination shows age-appropriate nuclear sclerotic changes in both eyes. Intraocular pressures are 16 in each eye. Fundus examination shows the retina to be attached 360 degrees without any tears or holes. There are peripheral and extramacular drusen in both eyes. There is no subretinal fluid or hemorrhage present. There is a mild and a stable epiretinal membrane in the right eye. OCT examination shows no subretinal fluid or macular edema in both eyes. There is a stable epiretinal membrane in the right eye.
ASSESSMENT AND PLAN: The patient is very stable from a retinal standpoint. We reassured her of these findings. At this point, we recommend annual monitoring.