Ophthalmology - Sample History

ACCM · **Ophthalmology - Sample History -** 13-12-2006, 12:27 PM

Here you can find sample history in Ophthalmology.

You can also submit sample history, some of the selected histories will be published in the next edition with the acknowledgement.

ACCM · 01:00 PM

History

Particulars

Name: Mr. K. Thapa
Age: 64 years Sex: Male
Religion: Hindu
Education: Primary level
Occupation: Carpenter
Marital Status: Married
Address: Thimi
Date of examination: 8th Nov 06’
Mode of admission: OPD
Date of admission: 6th Nov 06’

Chief Complaints
Impairment of vision in right eye - 2 years

History of present illness
According to the patient, he was apparently well 2 years back and then he had impairment of vision of right eye which was painless and getting worse day by day. Both near and distant vision was affected, the day vision was affected more than the night vision. There was mild discomfort, watery discharge, unable to see in bright light, black floaters, colored halos and diplopia as well.
No history of redness, foreign body sensation, itching, discharge and trauma to the eye.

Past history
He had been operated in left eye 4 months back for cataract (Extra Capsular Cataract Extraction with Posterior Chamber Intraocular Lens)

Personal History
• Bowel - normal
• Appetite - normal
• Sleep – not altered
• Urination – normal
• Non - Smoker
• Non - Alcoholic
• Diet: Non vegetarian

Family History
There is no history of ocular disease and other medical diseases in the family.

Socioeconomic History
He is a carpenter by occupation, from lower class joint family with seven members, poor housing condition with poor sanitation, water and toilet facilities.

Drug & Allergy History
No known history of allergy to drug, dust, food and sunlight.

Clinical Examination

A. General Examination

1. General Characteristics

Appearance: well looking
Co-operation: Cooperative
Oriented to Time, Person and Place
Body built: Averagely built
Nutritional status is good

Pallor – Not present
Icterus – Not present
Lymphadenopathy – Not present
Leuconychia – Not present
Clubbing – Not Present
Cyanosis – Not present
Oedema – Not Present
Dehydration – Not present

2. Vitals

Pulse: 80/min, right radial, semi-supine in position, regular in rhythm, large in volume and normal in character, condition of arterial wall is normal, no radio-radial and radio-femoral delay and all peripheral pulses are palpable.
Blood pressure: 120/80 mm of Hg in the right arm in sitting position.
Respiration: 18/min in sitting position, normal in depth, thoraco-abdominal type
Temperature: 98ºF in axilla
JVP: Not raised

B. Systemic Examination
Respiratory system: Bilateral Vesicular sound heard, no added sound.
Cardiovascular System: First and second heart sound heard, no murmur.
Central Nervous System: Intact
Alimentary system: soft, flat, symmetrical abdomen with normal bowel sounds.

C. Ocular Examination

Visual acuity Right eye Left eye
Distant vision Unaided 5/60 6/24
Distant vision Pinhole 6/36 6/12
Near vision N 36 N 18
Color vision normal normal
Light perception present present
Light projection present in all quadrants present in all quadrants
Cover – uncover test no strabismus no strabismus

(Detail on ocular exmination available in the book)

Provisional Diagnosis
Immature senile cataract in right eye, pseudophakia in left eye

Differential Diagnosis

Corneal degeneration
Corneal dystrophies
Optic atrophy
Diabetic retinopathy

Investigation

Blood sugar
Blood pressure
Tonometry
Biometry
Slit lamp examination

Final Diagnosis

Management

Source:

Sanju · **Re: Ophthalmology - Sample History -** 02-10-2007, 10:16 AM

History

Particulars

Name: Ram Prasad Sharma
Age: 49 years Sex: Male
Religion: Hindu
Education: Secondary level
Occupation: Business
Marital Status: Married
Address: Sinamangal
Date of examination: 8th Sept 07’
Mode of admission: OPD

Chief Complaints
Impairment of vision in left eye - 1 and half month
Watering of both eyes for 1 and half months

History of present illness
According to the patient, he was apparently well 1 and half month back, then he developed diminished vision of left eye, insidious in onset, both near and distant vision, transient with no diurnal variations, no region involvement, no intolerance to bright light, no pain but mild discomfort, no color halos, no double vision but associated with mild watering of eyes.d distant vision was affected, the day vision was affected more than the night vision. Watering of both eyes since 1 and half month, insidious, mild, on and off.
No history of redness, foreign body sensation, itching, discharge and trauma to the eye.

Past history
He had used glasses for near vision 10 years back for 8 years.
No H/O of DM, HTN, Asthma, Tb.
No eye surgery.

Personal History
• Bowel - normal
• Appetite - normal
• Sleep – not altered
• Urination – normal
• Smoker ( 24 pack year)
• Alcoholic ( 25 ml per day for 25 years)
• Diet: Non vegetarian

Family History
There is no history of ocular disease and other medical diseases in the family.

Socioeconomic History
He is a businessman by occupation, from lower middle class family.

Drug & Allergy History
No known history of allergy to drug, dust, food and sunlight.

Clinical Examination

A. General Examination

1. General Characteristics

* Appearance: well looking
* Co-operation: Cooperative
* Oriented to Time, Person and Place
* Body built: Averagely built
* Nutritional status is good

Pallor – Not present
Icterus – Not present
Lymphadenopathy – Not present
Leuconychia – Not present
Clubbing – Not Present
Cyanosis – Not present
Oedema – Not Present
Dehydration – Not present

2. Vitals

Pulse: 86/min, right radial, sitting in position, regular in rhythm, large in volume and normal in character, condition of arterial wall is normal, no radio-radial and radio-femoral delay and all peripheral pulses are palpable.
Blood pressure: 130/80 mm of Hg in the right arm in sitting position.
Respiration: 16/min in sitting position, normal in depth, thoraco-abdominal type
Temperature: 98ºF in axilla
JVP: Not raised

B. Systemic Examination
Respiratory system: Bilateral Vesicular sound heard, no added sound.
Cardiovascular System: First and second heart sound heard, no murmur.
Central Nervous System: Intact
Alimentary system: soft, flat, symmetrical abdomen with normal bowel sounds.

C. Ocular Examination

Visual acuity Right eye Left eye
Distant vision Unaided 6/24 6/36
Distant vision Pinhole 6/9 6/12
Near vision N 10 N 10
Color vision normal normal
Light perception present present
Light projection present in all quadrants present in all quadrants
Cover – uncover test no strabismus no strabismus
Extraocular mucsle movement:
-Uniocular: Full and adequate
-Binocular: Full and adequate
Head postures normal
Facial symmetry normal
Eyelids:
-Position: normal
-Skin: normal
-Margin: normal
-Palpebral aperture: normal
Eyebrows: Normally placed and normal hair follicles
Lacrimal apparatus:
-Lacrimal Gland: normal
-Puncta: normal
-Regurtitation test: positive
Conjunctiva:
-Bulbar: normal
-Upper palpebral: normal
-Lower palpebral: normal
Sclera: normal
Cornea: Rgular, round and reactive
AC deoth: normal
Iris: normal color, pattern.
Pupil: central location, direct and indirect reflexes present.
Lens: Normal in right eye, Central opacity in left eye
Fundus: normal

Differential diagnosis:
1. Refractive error
2. Presbyopia
3. Age related cataract
4. Galucoma
5. Age related macular degeneration (only with history)
6. Toxic optic atrophy

Investigations:
1. VA
2. Oblique illumination
3. Iris shadow
4. Distant direct ophthalmoscopy
5. Slit lamp examination
6. IOP measurement
7. Blood sugar etc.

Prvosional Diagnosis: Post capsular cataract