Table 7 Clinical Case Documentation Generated by Large Language Model

From: Enhancing clinical documentation with voice processing and large language models: a study on the LAOS system

Components

Clinical Documentation

Chief Complaint

Painless, progressive decline in left eye vision for 5 years.

Present Illness

Patient experienced blurred vision in left eye 5 years ago without obvious cause. Vision deterioration was gradual, without pain or distension. Currently reports notable visual impairment affecting daily life. Medical history includes well-controlled hypertension and diabetes. No history of high myopia.

Physical Examination

Right Eye: Visual acuity 0.1, cortical lens opacity, scattered vitreous opacities, clear disc margin with flat retina, IOP 10.5mmHg.

 

Left Eye: Visual acuity 0.05, significant cortical and nuclear lens opacity, scattered vitreous opacities, clear disc margin with flat retina, IOP 11.3mmHg.

Assessment

Pre-operative ophthalmological and systemic examinations for left eye cataract surgery reveal no contraindications.

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