Guest guest Posted January 6, 2008 Report Share Posted January 6, 2008 ----- Original Message ----- > Any specialists out there? At this stage, I am only trying to make sense > of > this super-fuzzy scanned fax of a fax of a photocopy that a client has > sent > me for provisional assessment. I do know that the patient had catarct > surgery > and has an implanted PCIOL in situ, but a lot of the stuff is illegible. > And > I have done very little ophthalmology so far. > > For example, I can just about make out > > V.A. (=visual acuity) 6/24 > IOP (=intraocular pressure) 13 > Cornea with Descemet folds > > but then there is something that may or may not be 'deep fundus' (???) > 'pressure' (???) [something] +2, [something] + > > - any idea what those numbers could refer to, in this context? > > Many thanks, > > I do a lot of ophthalmology, and the three you mention as solved look right, but if you could give us a better picture of what you are sure of and how many letters are missing (or illegible) for your question terms, as well as more context (are these all exam findings, for instance? -or could this be a procedure?) it might help. There is nothing harder than trying to read illegible text via a description, and so the description at least has to try to portray the physical layout (apparent number of letters, etc.). Even then, nothing can be certain, so I sometimes query the client as to " what the hell it says " (sorry for language, but clients have to stop using poor images instead of transcribing text! -they are going to end up killing people with misinterpretations!) Burns Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 6, 2008 Report Share Posted January 6, 2008 Dear , You are quite right. Here is some more info. This is from a hospital discharge report (the patient, a male aged 65, appears to be taking part in a clinical study, so I assume the sponsor is being informed routinely of all SAEs/interventions/etc, but I don't know what the study is about; internal evidence suggests that it's about prostate cancer). Thank you for any suggestions, Diagnoses: -Cataract extraction with IOL: phacoemulsification, Rt -IHD -CHF -TCC of prostate -Chemotherapy Discussion: Had elective surgery to remove cataract in right eye under LA Lens: B lens + 21.00 D On discharge: RE: Visual acuity: 6/24 with pinhole 6/21 Intra-ocular pressure: 13 Irritated conjunctiva Cornea central epithelial oedema stromal oedema with Descemet folds. [Deep?] [2-letter abbreviation, either of which may or may not be 'f'] [1-letter abbreviation]+2, [1-letter abbreviation]+ Pupil round PCIOL in situ Disc normalRetina attached ---------------------- Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 7, 2008 Report Share Posted January 7, 2008 Hello , I'm sorry I can't be of any great help with your text, but 's suggestions echo my thoughts. 's last comment reminds me of a recent question on another site regarding " amputation de la jambe " , in which one person, claiming to be a physician, insisted that this could only mean an above-knee amputation. Very scary indeed! cheers Sue Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 7, 2008 Report Share Posted January 7, 2008 ----- Original Message ----- > Dear , > > You are quite right. Here is some more info. > This is from a hospital discharge report (the patient, a male aged 65, > appears to be taking part in a clinical study, so I assume the sponsor is > being > informed routinely of all SAEs/interventions/etc, but I don't know what > the > study is about; internal evidence suggests that it's about prostate > cancer). > > Thank you for any suggestions, > > > Diagnoses: > -Cataract extraction with IOL: phacoemulsification, Rt > -IHD > -CHF > -TCC of prostate > -Chemotherapy > > Discussion: > Had elective surgery to remove cataract in right eye under LA > Lens: B lens + 21.00 D > > > On discharge: > RE: > Visual acuity: 6/24 with pinhole 6/21 > Intra-ocular pressure: 13 > Irritated conjunctiva > Cornea central epithelial oedema stromal oedema with Descemet folds. > [Deep?] [2-letter abbreviation, either of which may or may not be 'f'] > [1-letter abbreviation]+2, [1-letter abbreviation]+ > Pupil round > PCIOL in situ > Disc normalRetina attached My sympathies, it sounds like this is really hard to read. I don't have any brilliant thoughts, but perhaps you could see if the following look possible: > [Deep?] [2-letter abbreviation, either of which may or may not be 'f'] Could it be " Direct " instead of " Deep " ? Even if that is the case, I am guessing, but I see " direct fundoscopy " a lot in such circumstances, and I remember you earlier thought " fundus " might be in there. I would at least expect to see some kind of fundoscopy (AKA: opthalmoscopy) done -there are also " indirect " and " slit-lamp " versions. > [1-letter abbreviation]+2, [1-letter abbreviation]+ Just from having two readings, this looks as though it could be a left-right reading, however, just to keep us on our toes, they like to use the latin abbreviations ( " d " and " s " ), often as os - od (o=oculus) -I forget which one is always supposed to be first, but they supposedly have to always start with the same eye -which doesn't mean they all do. Even if somehow these look perfect, I would suggest a TN saying something like " illegible, possibly blah. blah. blah " -It sounds as though this is background information on your document, but I have nightmares about some doctor operating on me based on an illegible abbreviation. I hope this helps, sorry I can't be at all certain. Burns Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 7, 2008 Report Share Posted January 7, 2008 Many thanks, . Bearing in mind the risk of surgery based on highly speculative (no pun intended) information, stressed by Sue also, I have added a clear TN (and in any case, placed square brackets + question marks around these phrases), plus an unambiguous statement of my opinion of this text ... Cheers, Quote Link to comment Share on other sites More sharing options...
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