眼科模板范本（Ophthalmic template）.docVIP

眼科模板范本（Ophthalmic template） Graveseye specialist medical records: first part Duration record 2004-10-31 [purpose of the visit (proptosis, re examination, visual acuity), diagnosis, treatment. ] Chief complaint: Current medical history: due to Main symptom Photophobia, tears, foreign body sensation: No, there is. Eye pain, orbital pain: [there is] nothing Abstract: there is no envy Diplopia Blurred vision, descent, or blindness Clinical examination: (1) vision: uncorrected vision (corrected vision): Right: Left: (2) intraocular pressure: (3) orbital pressure: normal [[suspicious] increase [].] (4) light localization: (5) red green color vision: (6) eyelid condition: Eyelid swelling [[]] [no] extent: Eyelid retraction: [no] extent: Eyelid lag: [no] to a certain extent: Eyelid closure: [absence of] [degree]: mm. (NATURAL eyes closed) (7) eye position and eye movements [first eye]: [eyeball movement is limited] [one-way] [multidirectional] [passive traction test] [positive] negative (8) palpebral fissure size, upper eyelid muscle strength: right palpebral fissure length mm; width: mm; left eyelid length mm; width: mm; lower eyelid height when looking down: Right: mm; Left: mm. closes the eyelid when the eyelid crack can shut. Can not, when eyelid closed palpebral fissure height: mm. (9) corneal involvement: [no] [I have]. Description: corneal punctate epithelium shedding [corneal ulcer] Bulbar conjunctiva: congestion and edema [no]; description: Degree: Bulbar conjunctiva hyperemia and edema in only the extraocular muscles Bulbar conjunctiva hyperemia and edema were increased, but the position was removed from palpebral fissure The bulbar conjunctiva is removed from the palpebral fissure The anterior chamber, the aqueous humor, the iris, the lens and vitreous body, and the retina: The optic papilla border blurred and the vein dilated slightly Optic disc edema Optic atrophy (10) imaging findings: CT or MRI examination of orbit: Muscular hypertrophy of the eye Single eye