Ophthalmology case history taking
Demographic data
Date of examination:
Name: Age:
Occupation: Sex:
Address: Socioeconomic status:
Chief complaints
Patient presented with diminution of vision in _______ eye for past __________ and diminution of vision in
________eye for past __________
History of Presenting illness
Patient was apparently normal before _________ then he/she developed diminution of vision in _____ eye,
followed by _______ eye.
- Insidious or abrupt onset?
- Progressive or sudden in nature?
- Associated with pain or not?
- Diminution of vision was same for both distance and near vision, associated with glare or not?
- Associated or not associated with the following?
- Watering of eyes
- Itching
- Redness
- Colored haloes
- Foreign body sensation
- Diplopia
- Discharge
- h/o ocular surgery?
- h/o trauma?
Past History
H/o Hypertension, Diabetes mellitus, Asthma, Tuberculosis, Epilepsy, COPD, Allergy?
Family History
Significant family history- yes/no? if yes?
Personal History
-Diet? (Mixed/ veg/ nonveg)
- Appetite? Normal / Loss
- Bowel and Bladder movements – Normal or abnormal?
- Sleep – Normal or any disturbances?
- H/o of smoking, tobacco chewing?
- H/o of alcohol consumption?
Examination
a) General examination:
Vitals- Temp: BP:
Pulse rate: Respiratory rate:
Signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema? (PICCLE)
b) Systemic examination:
- CNS- NFND (no focal neurological deficit)
- CVS- S1, S2 heard
- RS- Vesicular breath sounds heard
c) Ocular examination:
- Head posture: Straight and erect
- Facial symmetry: Symmetrical or asymmetrical?
- Ocular symmetry: Right eye-
Left eye-
(Orthotropic, Exotropia, Esotropia, Hypertropia, Hypotropia)
Features Right eye Left eye
1. Visual acuity
2. Ocular movement Full and free/ Fixed Full and free/ Fixed
3. Eyebrow
4. Eyelid
5. Eyelashes
6. Conjunctiva:
-Palpebral
-Bulbar
7. Cornea - Transparent - Transparent
- Normal in shape and size - Normal in shape and size
- Arcus senilis: - Arcus senilis:
- Corneal sensation present - Corneal sensation present
8. Anterior chamber:
- Depth Shallow / deep Shallow / deep
- Contents Normal contents Normal contents
9. Pupil:
- Size
- Shape
- Position
- Color
- Reflex: Direct
- Indirect
- Accommodation
10. Iris:
- Color
- Pattern
- Shadow
(If present
immature)
11. Sclera
12. Lens:
- Size
- Shape
- Color
(Milky white,
pearly white,
greyish white)
13. Lacrimal
apparatus:
- Punctum
- ROPLA’s test
14. Digital tonometry
Summary
_____ year old male/female coming to OPD with complaints of
_______________________________________________________________________________________
With or without history of previous ocular surgery?
On examination:
-
-
-
Diagnosis:
Right eye-
Left eye-
Treatment:
