CASE SHEET

Name:

Age:

Sex:

Occupation:

Address:

CHIEF COMPLAINTS: (Chronological Order)

Came to the OPD with symptoms & duration

HISTORY OF PRESENTING ILLNESS:

The patient was apparently normal _____ days / weeks / months before. He presented with

❖ H/o Defective / Blurring of vision

o Which eye?
o Duration
o Onset
o Progression
o Aggravating & Relieving factors (Diurnal variation)
o Associated conditions
❖ H/o Coloured Halos
o Which eye?
o Duration
o Onset
o Progression
o Aggravating & Relieving factors (Diurnal variation)
o Associated conditions
❖ H/o Glare
o Which eye?
o Duration
o Onset
o Progression
o Aggravating & Relieving factors (Diurnal variation)
o Associated conditions
❖ H/o Double vision / Multiple images
o Which eye?
o Duration
o Onset
o Progression
o Aggravating & Relieving factors (Diurnal variation)
o Associated conditions
❖ H/o Watering / Discharge from eye
o Which eye?
o Duration
o Onset
o Progression
o Consistency
 o Aggravating & Relieving factors (Diurnal variation)
o Associated conditions
❖ H/o Redness
o Which eye?
o Duration
o Onset
o Progression
o Aggravating & Relieving factors (Diurnal variation)
o Associated conditions
❖ H/o Pain (Eye ache / Headache)
o Which eye?
o Duration
o Onset
o Nature
o Intensity
o Progression
o Aggravating & Relieving factors (Diurnal variation)
o Associated conditions
❖ H/o Burning / Itching / Foreign body sensation
o Which eye?
o Duration
o Onset
o Progression
o Aggravating & Relieving factors (Diurnal variation)
o Associated conditions
❖ H/o Photophobia
o Which eye?
o Duration
o Onset
o Progression
o Aggravating & Relieving factors (Diurnal variation)
o Associated conditions
❖ H/o Trauma
o Which eye?
o When?
o Region of injury
o Type of injury
o Mode of injury
o Associated with loss of consciousness
o Management done
❖ H/o Chronic drug usage
o Reason for usage
o Duration of use
o Regular / Irregular usage
o Was the condition controlled by the drug use?
❖ H/o Chronic Radiation Exposure
o Where?
o How long?
❖ H/o Toxic substance Exposure
o Which substance?
o How long?
o Which region was exposed?
o Management
 ❖ H/o Electric Impulse Exposure
o Source
o How long?
o Which region was exposed?
o Management
❖ H/o Chronic Immunodeficiency
o Reason
o Management
❖ H/o Chronic Skin disease
o Cause
o Management

PAST HISTORY:
❖ H/o Similar episodes in the past
o When?
o How?
o Duration
o Progressiveness
o Treatment
❖ H/o Similar complaints of the other eye
o When?
o How?
o Duration
o Progressiveness
o Treatment
❖ H/o Previous loss of visual acuity
o Type of loss – with power
o When was it diagnosed?
o Type of Correction, if done
o Most recent check up

Surgical History:
❖ H/o Past Surgeries -
o Site
o Year
o Reason
o Hospital done
o Post-Operative Complications
❖ H/o Past Ocular Surgeries –
o Left / Right Eye
o Year
o Reason
o Type of surgery
o Hospital Done
o Intra and Post-Operative Period (uneventful)
o Follow-up

Medical History:
❖ Known case of Diabetes Mellitus
o Duration
o Medication
▪ Type
 ▪ Duration
▪ Regular / Irregular
o Controlled / Uncontrolled
❖ Known case of Hypertension
o Duration
o Medication
▪ Type
▪ Duration
▪ Regular / Irregular
o Controlled / Uncontrolled
❖ Known case of Ischemic Heart Disease
o Duration
o Medication
▪ Type
▪ Duration
▪ Regular / Irregular
o Controlled / Uncontrolled
❖ H/o Bronchial Asthma
o Duration
o Medication
▪ Type
▪ Duration
▪ Regular / Irregular
o Controlled / Uncontrolled
❖ H/o Tuberculosis
o Duration
o Medication
▪ Type
▪ Duration
▪ Regular / Irregular
o Controlled / Uncontrolled
❖ H/o Epilepsy / Cerebo-vascular accident
o Duration
o Medication
▪ Type
▪ Duration
▪ Regular / Irregular
o Controlled / Uncontrolled

TREATMENT HISTORY:
❖ H/o Past Ocular / Systemic Medications
o When?
o Reason for usage
o Duration of use
o Regular / Irregular usage
o Was the condition controlled by the drug use?
o Adverse reactions, if any
❖ H/o Drug allergies & other allergies

PERSONAL HISTORY:
❖ H/o Chronic Smoking
❖ H/o Chronic Alcohol Usage
 ❖ Dietary History
❖ Sleep Pattern – hours of sleep
❖ Bowel & Bladder Habits

FAMILY HISTORY:
❖ H/o similar episodes in family members (If not – write no relevant family history)
o Who had it?
o Onset / Age of occurrence
o Progression
o Treatment
❖ H/o Anticipation (If both Parents had it)

GENERAL EXAMINATION
The patient is

1. Level of consciousness (Glasgow Coma Scale)

2. Orientation to time, place & person
3. Built & Nourishment
4. Febrile / Afebrile
5. Pallor
6. Icterus
7. Cyanosis
8. Clubbing
9. Pedal Oedema – pitting / non-pitting
10. Generalised lymphadenopathy

VITAL SIGNS
Pulse Rate:

Blood Pressure:

Respiratory Rate:

Temperature: (Only if required)

SYSTEMIC EXAMINATION:
CVS: S1S2 normally heard, No Added sounds / Murmurs

RS: Normal Vesicular Breath sounds heard

Per Abdomen: Soft, Non-tender, No organomegaly, Normal bowel sound heard

CNS: No focal neurological deficit

OCULAR EXAMINATION:
❖ Head Position
❖ Facial Symmetry
❖ Orthophoria (Hirschberg Test)
EXAMINATION OF EYE:

RIGHT EYE LEFT EYE

Swelling in the Lacrimal Region -
❖ Inspection:
o Site
o Size (vertical &
horizontal)
o Shape
o Colour
o Margins
o Number
o Skin over the swelling
❖ Palpation:
o Warmth
o Tenderness
o Site, Size, Shape,
Margins & Extent
o Consistency
o Fluctuation
o Fixity to skin
EYEBROW Normal Normal
EYELIDS Swelling Normal
❖ Inspection:
o Site (Medial / Middle /
Lateral 1/3rd)
o Size (Approx. vertical
& horizontal)
o Shape
o Colour
o Margins
o Number
o Skin over the swelling
o Pus point (location &
direction-towards /
away from lid margin)
❖ Palpation:
o Warmth
o Tenderness
o Site, Size, Shape,
Margins & Extent
o Consistency
EYELASHES Discharge & Crests Normal
CONJUNCTIVA Congestion – type (conjunctival / Clear
Circumciliary)
 Limbal Scar (Normal & healthy /
any prolapse)
Collection of Blood
❖ Site
❖ Size (vertical & horizontal)
❖ Shape
❖ Margins
❖ Colour (Bright red / Dull red)
❖ Extension
❖ Posterior limit (Seen / Not)
❖ Contusion, Raccoon eye,
Panda eye
Congestion – type (Conjunctival /
Circumciliary)
Pterygium –
❖ Site (Nasal / Temporal)
❖ Shape (Triangular) &
Extended __mm till _____
❖ Apex (pointing towards /
away from Cornea)
❖ Colour
❖ Infiltration (if present)
❖ Encroachment – size &
position
Bitot’s Spots – Dry, Silvery, Scaly
Appearence
CORNEA Ulcer – Clear
❖ Site (Central / Paracentral / Arcus Senilis is present
Peripheral) or (Clock
position)
❖ Size
❖ Shape
❖ Number
❖ Margin
❖ Edge (Everted / not)
❖ Base (Granulation tissue)
❖ Discharge
❖ Surrounding area
❖ Hypopyon
❖ Satellite Lesions
❖ Immune Ring
Corneal Reflux (In normal cornea –
present/absent)
 Opacity –
❖ Site (Central / Paracentral /
Peripheral) or (Clock
position)
❖ Size
❖ Shape
❖ Colour
❖ Margin
❖ Number
❖ Type
Encroachment of Pterygium at __o
clock position __mm
Other part of cornea - clear
ANTERIOR CHAMBER Shallow Normal in depth
Deep
Deep
IRIS Iridodonesis Normal in colour &
pattern
PUPIL Jet Black Pupil Single, centrally placed,
Size=3mm, Reacting to
direct & indirect light
reflexes
LENS Absent Clear
Greyish White / Pearly White /
Milky White / Dirty White Opacity
Blackish / Brownish / Amber /
Yellowish / Reddish Opacity
Glistening Light Reflex Present -
due to PC-IOL Implantation
Iris Shadow is seen
VISUAL ACUITY Improvement with Pin-hole 6/6, NIPH
EXTRA-OCULAR MUSCLE ❖ Which action is impaired? Fully Ranged
MOVEMENT ❖ Muscle & nerve involved
(UNIOCULAR &
BINOCULAR)
DIGITAL TONOMETRY Hard / Rigid or Soft (Balloon-like) Normal
ROPLAS Positive (Regurgitation / Discharge Negative
is present)
 Dacryocystitis
Hordeolum externum / Hordeolum internum / Kalazion
Corneal Ulcers
Immediate Post-op Aphakia / Pseudophakia
Sub-conjunctival Haemorrhage
Corneal Opacity
Aphakia
Pseudophakia
Immature Cataract
Nuclear Cataract
Pterygium

DIAGNOSIS:
RIGHT EYE:
LEFT EYE:

MANAGEMENT:
• INVESTIGATIONS:
• TREATMENT:
o Surgical:
o Medical: