272 Medical Terminology: Mastering the Basics CHART NOTE Patient Name: Jacobowitz, Maria ID Number: MJ3321 Examination Date: August 12, 20xx SUBJECTIVE This 32-year-old female was struck in the left eye by the slats of a mini-blind, lacerating (scratching or tearing) the sclera. Mild pain was noted but no immediate visual problems, no photophobia (extreme sensitivity to light), and no blurred vision. OBJECTIVE There appears to be an abrasion of the left sclera with surrounding subconjunctival (below the membrane that lines the eyelids) hematoma. Pupils are equal, regular, and reactive to light. There does not appear to be any involvement of the cornea. Fluorescein stain shows some mild uptake over the injury site. ASSESSEMENT Scleral abrasion, left eye. PLAN Patient should apply Garamycin® ophthalmic solution (antibiotic medication), 1–2 drops to left eye every 4 hours for 3 days. Recheck if problem continues or symptoms worsen. Assessment Interpret Maria Jacobowitz’s Chart Note Directions: After listening to the dictated recording and reading the chart note on Maria Jacobowitz, provide the medical term that matches each defi nition below. Example: inflammation of the retina Answer: retinitis 1. clear, outer layer of the eye that covers the iris and pupil, and admits light ________________________________________________ 2. extreme sensitivity to light ________________________________________________ 3. below the membrane that lines the eyelids ________________________________________________ 4. white, outer protective layer of the eye ________________________________________________ 5. pertaining to the eye ________________________________________________ SCORECARD: How Did You Do? Number correct (_____), divided by 5 (_____), multiplied by 100 equals _____ (your score)