Tina Tep

Carnes
Health Sciences II
21 April 2018
 

Case Study  
 
Patient: ​XXXXX YYYYY  Highest Grade Completed: ​N/A 
Birth-date: ​N/A  Sex: ​Female 
Place of birth: ​N/A Language Spoken: ​English  
Marital status: ​N/A Occupation: ​Bookkeeper at Key-Bank  
 
Chief Complaint: ​Would like to discuss about ocular migraines. Concerned whether this could happen when driving to 
or back from places.   
 
Present Illness: ​Optical migraine twice in one day but has not had one ever since. She blacked out for a couple of 
seconds and for about a minute without realizing she spaced out.  
 
Symptoms: 
Type: ​Optic migraine   
Severity: ​Mild 
Location: ​Optic nerve 
Duration: ​Twice within 2 days that lasted between a couple of seconds or a minute  
Influencing factors: ​Heredity (daughter seeked neurologist and cardiologist b/c she blacks out after tests).   
History of present illness: ​None 
Allergies: ​None 
Current drugs:​ Daily Multivitamin 
Smokes: ​No 
Drinks: ​Yes 
Previous treatment: ​Eye dilation using anesthetic ophthalmic drops and fluorescent dyes  
Previous medical problems: ​Persistent in seeking primary care physician, optometrist, and hygienist for 
annual health exams, and a neurologist and cardiologist for her daughter's optic migraines 
Surgeries: ​Cholecystectomy (incision to remove the gallbladder)  
 
Diagnosis:  
The phoropter and slit lamp were used between 10:00am-10:25am on Saturday, December 16, 2017. The 
patient is asked to read the Rosenbaum eye chart and to repeat each letter from left to right and shows that 
there is a slight change from her old prescription, but the patient’s eyes remain stable. The patient should call 
or schedule a follow up appointment if any symptoms reoccur or worsens.