C A S E R E P O R T

O p h t h a l m o l o g i c a l d e p a r t m e n t

Chief of department: Vitovska Oksana

MD, professor.

 

Curator of the group: Churiumov D.S.

C A S E R E P O R T

Patient’s name
	Age
Diagnosis

Student
Faculty
Course		Group

 

Kyiv - 2015
I. PASSPORT DATA

Name _____________________________________________________________________________

Date of birth «_____»______________ 20______ Age _________ Sex _____________

Date of admission «_____»______________ 20______, Urgency _____________________________

Hospital ___________________________________________________________________________

Profession _________________________________________________________________________

II. INTERROGATION

Complaints ________________________________________________________________________

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Anamnesis morbi ___________________________________________________________________

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Anamnesis vitae (Present history, Past history, Personal and professional history)

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III. STATUS PRAESENS OBJECTIVUS COMMUNIS

General state _______________________________________________________________________

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Skin, Locomotive system _____________________________________________________________

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Cardiovascular system _______________________________________________________________

______________________________________________________ AT ________/_________mm Hg __________________________________________________________________________________

Respiratory system __________________________________________________________________

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Digestive system ____________________________________________________________________

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Nervous system, ____________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Endocrine glands ___________________________________________________________________

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Urogenital system ___________________________________________________________________

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VI. LOCAL OPHTHALMOLOGICAL STATE

#	Item	Right Eye (OD)	Left Eye (OS)
	Visual acuity (without correction, with correction)
	Clinical refraction
	Peripheral vision (by a control method or on a perimeter)
	Colour vision.
	Binocular vision.
	Dark adaptation
	Eye fissure (position, sizes)
	Eyelids (position, growth of cilia)
	Lacrimal organs (state, ability for drainage, tests).
	Eyeball (position, mobility, convergence),
	Intraocular pressure
	Conjunctiva (colour, mobility, vessels),
	Cornea (transparency, sensitiveness, sizes, curvature)
#	Item	Right Eye (OD)	Left Eye (OS)
	Limbus (width, changes)
	Sclera (colour, vessels)
	Anterior chamber (state of fluid, depth, sizes)
	Iris and (colour, picture, form)
	Pupil (direct and concord reaction on light, reaction on convergence and accommodation)
	Ciliary body (pain, sensitivity)
	Lens of the eye (transparency, position)
	Vitreous body (transparency)
	Reflex from Eye fundus (color, brightness, regularity)
	Eye fundus picture: Optic nerve disk - color, size, shape, position Retinal vessels – caliber, regularity, relativeness a/v Central part: region of yellow spot, reflexes Periphery. Focal changes
Optic nerve disk _____________ __________________________ Retinal vessels ______________ __________________________ Central part ________________ __________________________ Periphery __________________ __________________________	Optic nerve disk _____________ __________________________ Retinal vessels ______________ __________________________ Central part ________________ __________________________ Periphery __________________ __________________________

 

VII. INFORMATION OF ADDITIONAL EXTERNAL EXAMINATIONS

AND SPECIAL RESEARCHES

 

General examination

Blood ____________________________________________________________________________

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Urine _____________________________________________________________________________

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X-ray, MRT: ______________________________________________________________________ __________________________________________________________________________________

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Ultrasonic _________________________________________________________________________ __________________________________________________________________________________

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Consultations (therapeutist, otorhinolaringologist, neurologist, etc.):

__________________________________________________________________________________

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Other researches depending on pathology (conclusions).

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Fluorescent test ____________________________________________________________________

Shirmer’s test ______________________________________________________________________

 

Diurnal tonometry, mm Hg:

 

Day
OD
OS

 

VIII. DIAGNOSIS

Ground of diagnosis. Differential diagnosis.

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Clinical diagnosis.

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IX. TREATMENT

(surgical, medicinal, local and systemic)

Surgical treatment ___________________________________________________________________ __________________________________________________________________________________

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Medicinal _________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________

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Prescriptions:

Rp.: ________________________________ ________________________________ ________________________________ ________________________________ ________________________________		Rp.: ________________________________ ________________________________ ________________________________ ________________________________ ________________________________
Rp.: ________________________________ ________________________________ ________________________________ ________________________________ ________________________________		Rp.: ________________________________ ________________________________ ________________________________ ________________________________ ________________________________

 

Physiotherapy ______________________________________________________________________ __________________________________________________________________________________

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Other _____________________________________________________________________________

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X. VISUAL (Functional) PROGNOSIS AND RECOMENDATIONS

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Student’s signature _________________

Signature of curator _________________