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    Ophthalmology Case Profoma - Agam

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    Harshitha A
    This document contains a template for documenting an ophthalmology case history and examination. It includes sections for collecting the patient's demographic details, chief complaints, history of present illness, past medical history, personal history, family history, and results of a general and ocular examination. The examination section includes assessing visual acuity, the eyebrows, eyelids, lacrimal apparatus, orbit, eyeball, conjunctiva, cornea, anterior chamber, iris, pupil, and lens. The document concludes with space for a provisional diagnosis and sample viva questions to ask the patient.

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    Ophthalmology Case Profoma - Agam

    Uploaded by

    Harshitha A
    128 views8 pages
    This document contains a template for documenting an ophthalmology case history and examination. It includes sections for collecting the patient's demographic details, chief complaints, history of present illness, past medical history, personal history, family history, and results of a general and ocular examination. The examination section includes assessing visual acuity, the eyebrows, eyelids, lacrimal apparatus, orbit, eyeball, conjunctiva, cornea, anterior chamber, iris, pupil, and lens. The document concludes with space for a provisional diagnosis and sample viva questions to ask the patient.

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    This document contains a template for documenting an ophthalmology case history and examination. It includes sections for collecting the patient's demographic details, chief complaints, history of present illness, past medical history, personal history, family history, and results of a general and ocular examination. The examination section includes assessing visual acuity, the eyebrows, eyelids, lacrimal apparatus, orbit, eyeball, conjunctiva, cornea, anterior chamber, iris, pupil, and lens. The document concludes with space for a provisional diagnosis and sample viva questions to ask the patient.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    128 views8 pages

    Ophthalmology Case Profoma - Agam

    Uploaded by

    Harshitha A
    This document contains a template for documenting an ophthalmology case history and examination. It includes sections for collecting the patient's demographic details, chief complaints, history of present illness, past medical history, personal history, family history, and results of a general and ocular examination. The examination section includes assessing visual acuity, the eyebrows, eyelids, lacrimal apparatus, orbit, eyeball, conjunctiva, cornea, anterior chamber, iris, pupil, and lens. The document concludes with space for a provisional diagnosis and sample viva questions to ask the patient.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 8

    Agam - Ophthalmology Case Profoma

    History:
    Demographic details:
     Name:
     Age:
     Sex:
     Occupation:
     Locality:

    Chief complains:

    History of presenting illness:


    The patient was apparently normal before ______, after which he/she developed
    1. Decreased vision – Left or Right or Both eyes
    a. Onset
    b. Progression or non-progressive
    c. Near or far vision
    d. Diurnal variation
    e. Aggravating and relieving factors
    f. Associated factors

    2. Mass on Right or Left eye


    a. Onset
    b. Progressive or non-progressive
    c. Associated factors:
    i. Diplopia
    ii. Irritation
    iii. Foreign body sensation
    iv. Redness

    3. Discharge
    a. Onset
    b. Duration
    c. Amount of discharge

    1
    d. Type of discharge
    e. Diurnal variation
    f. Aggravating and relieving factor

    4. Other histories: (after describing chief complains)


    a. H/O Pain
    b. H/O redness
    c. H/O diplopia, polyopia
    d. H/O photophobia
    e. H/O colored halos
    f. H/O flashes
    g. H/O floaters
    h. H/O glare
    i. H/O trauma
    j. H/O foreign body sensation

    Past history:
    o H/O similar complaints in the past
    o H/O other ocular complaints
    o H/O any systemic illness:
     Diabetes mellitus
     Hypertension
     Asthma
     Tb
     Epilepsy
     Coronary artery disease
    Duration, treatment – regular or irregular and type of medication
     H/O surgical history

    Personal History:
     Diet
     Sleep
     Appetite
     Bowel and bladder movements
     Alcohol, smoking

    Family history:
     If any, to be mentioned

    2
    Examination:
    General Examination:
     Built and nourishment
     Consciousness and orientation
     Vitals
    o Temperature
    o Blood pressure
    o Respiratory rate
    o Pulse rate
     Palor, icterus, clubbing, cyanosis, lymphadenopathy, pedal oedema

    Systemic examination:
     Central Nervous System
    o Cranial nerves intact
    o Superficial and deep reflexes normal
     Cardiovascular System
    o S1 and S2 heard
    o No abnormal sound heard
     Respiratory System
    o Normal vesicular breath sound
    o No added breath sound
     Abdomen
    o No organomegaly
    o No tenderness
    Ocular Examination:
     Head position
    o Tilt – lagophthalmuos, ptosis
    o Face turn - squint
    o Chin up/ down
     Facial symmetry

    Right Eye followed by left eye


    Visual acquity Improvement on pinhole?
    Eyebrow  Present or absent
     Extent – med. To lat. Canthus
    In supra orbital ridge
     Madarosis TB, Leprosy, radiation
     Poliosis senile
    Eyelids Closed:
    o Eyelid proper

    3
     Lagophthalmos 7th nerve palsy
     Check for bells phenomenon
     Surface - scar, swelling (chalazion, hordeolum internum), ulcer,
    elevation, depression
    Open:
     Interpalpebral fissure
    (9 to 11mm)
     Ptosis(<9mm)
     Lid Retraction (>11mm)
    o Lid margin
     Ectropion, Entropion
     Crusting, scaling, ulcer (ulcerative blepharitis)
     Ant. Border – round
     Post. Border – angulated
     Meibomian gland duct opening – normal
    o Eye lashes
     Madarosis, Poliosis
     Trichiasis (trachoma), Districhiasis

    Lacrimal Apparatus  Punctum (lower) – visible


     Signs of inflammation Dacryocystitis
     ROPLAs test

    Orbit and its contents


    Orbit (margin of  Inspection – scar, irregularity, swelling
    orbital inlet)  Palpation – irregularity, tenderness
    Eyeball Position, Visual access, Size, Movement
    Conjunctiva  Bulbar – color, congestion, chemosis, discharge, fleshy vascular mass,
    Bitot’s spot
     Palpebral – color, ulcer, swelling, concretions, papillae, follicle
     Fornix – congestion, discharge,
    Cornea  Dimension
     Edema
     Sensation
     Active ulcer – location, size
     Scaring – location(peripheral/pupillary), size
     Opacity

    Sclera  Color
     Signs of inflammation
     Traumatic perforation
     Dilation/bulging

    Anterior Chamber  Depth


     Eclipse sign

    4
     Hypopyon, hyphema
     Abnormal constituents present or absent

    Iris  Present / absent


     Colour
     Pattern
     Iris nodules iridocyclitis
     Iridodonesis

    pupil  Number of pupil


     Shape
     Pupillary light reflex

    Lens  Present/ absent/ IOL


     Transparency?
     greyish white, milky white, pearly white, dirty white opacity

    Provisional Diagnosis:

    5
    VIVA Questions
    1. Occupation related diseases
    a. Farmers – pterygium, cataract, traumatic fungal ulcers
    2. Loss of vision
    a. Sudden painful loss of vision
    i. Acute angle closure glaucoma
    ii. Iridocyclitis
    iii. Trauma
    1. Chemical
    2. Mechanical
    b. Sudden painless loss of vision
    i. CRAO
    ii. Massive vitreous haemorrhage
    iii. Ischemic CRVO
    c. Sudden painless defective vision
    i. Optic neuritis
    ii. Methyl alcohol amblyopia
    iii. Central serous chorioretinopathy
    iv. Non ischemic central vein occlusion
    d. Gradual painful defective vision
    i. Chronic iridocyclitis
    ii. Corneal ulceration
    e. Gradual painless defective vision
    i. Progressive pteryium
    ii. Corneal degeneration / distrophy
    iii. Developmental / senile cataract
    iv. Optic atrophy
    v. Chorioretinal degeneration
    vi. Age related macular degeneration
    vii. Diabetic retinopathy
    viii. Refractive errors

    3. Floaters
    a. Vitreous hemorrhage
    b. Vitreous degeneration

    4. Photopsia – flashes of light


    a. Posterior vitreous detachment
    b. Vitreous traction band

    6
    5. Photophobia
    a. Conjunctivitis
    b. Keratitis
    c. Anterior uveitis
    6. Coloured halos
    a. Intumescent cataract
    b. glaucoma

    7. Diplopia
    a. Uniocular
    i. Double pupil
    ii. Keratoconus
    iii. Incipient cataract
    b. Binocular
    i. Paralytic Squint

    8. DD mass in the eye


    a. Pterygium
    b. Pseudo-pterygium
    c. Pingicula

    9. Discharge
    a. Watery/ serous – viral
    b. Mucoid – allergic
    c. Stringy/ ropy – VKC/ spring catarrh
    d. Mucopurulent – acute conjunctivitis, bacterial, chlamydial
    e. Bloody (sanguinous) – gonococcal
    f. Purulent – gonococcal

    10. Colors of sclera


    a. Yellow – icterus
    b. Blue – cyanosis, thinning of sclera
    c. Brown – melanin deposition

    11. Corneal opacity grading


    a. Nebula
    b. Macula
    c. Leucoma

    7
    d. Adherent leucoma

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