Case History 

Name of the patient:

Age :
Sex:
Occupation:
Residence:
*referred consultation- if it is

Chief complaints - recorded in patients own words (redness , burning, light

flashes,mattering...)

History of presening illness:-

Time and manner of onset - sudden/gradual?

Severity - improved/worsened/remained the same?

Influences (exacerbations and remissions) - what might have precipitated thetcondition , made it
better or worse or no difference?

Constancy and temporal variatons-intermittent or seasonal or does it worsen at particular time of the
day?

Laterality : unilateral or bilateral?

Disturbances of vision (Specific complaints) :

Blurred or decreased central vision(distance or near or both)

Decreased peripheral vision

Altered image size(micropsia , macropsia, metamorphosia-distorted images)

Diplopia-(monocular,binocular,horizontal,verical,oblique)

Floaters(moving lines or specks in the field of vision)

Photopsias (flashes of light)

Iridescent vision (halos , rainbows)

Dark adaptation problems

Dyslexia (difficulty processing the writter word)

Color vision abnormalities

Blindness (ocular, cortical,perceptual)

Oscillopsia (apparent shaking of images)

Ocular pain / discomfort:

Foreign body sensation on the surface of the eye

Ciliary pain (deep)- within and around the eye and radiating to ipsilateral temple ,forehead, malar
area, occiput
Headache ,dryness, burning ,true itching
Photophobia (ciliary pain on exposure to light)
Asthenopia (eyestrain)

Abnormal ocular secretions :

Lacrimation
Epiphora (spilling of tears over the margin of the eyelid onto the face)
Dryness
Discharge(purulent , mucopurulent -associated with neutrophils and cause
true sealing of the eyelids in the morning ) , mucoid, serous,watery

Abnormal appearances :

Ptosis(drooping of the eyelid)

Proptosis or exophthalmos (protrusion of the eyes)
Enophthalmos(opposite of proptosis)
Blepharitis(granulated eyelids)
Misalignment of the eyes
Redness, other discolorations, opacities,masses
Anisocoria(asymmetric pupil size)
Trauma :
Date,time,place,safety precautions taken?,emergency treatment taken?
Vision affected? And foreign body -type and speed roughly

Past history (Ocular) -

prior eye diseases(lazy eye(amblyopia) / squints/
patching of the eye as a child ) , injuries, diagnoses, treatments, surgeries, ocular medications, and
use of glasses/contact lens wear

Systemic medications: (drug history) aspirin and Anticoagulants-cause intraoperative and

postoperative bleeding , Acetazolamide and And taken for ocular problems are to be noted

*antimalarials ,phenothiazines,amiodarone, tamoxifen, systemic

steroids-cause ocular toxicity
Anticonvulsants , sleeping pills,anti inflammatory agents, contraceptives to  be noted if taken

General medical and Surgical history : Diabetes -type and duration,STDs , HTN , paediatric
patient (pregnancy-prenatal care , drugs used ,
complications in labor, prematurity, delivery,birth rate,neonatal period)
Allergies : itching , hives , rashes, wheezing, cvs-rs collapse, atopic dermatitis, allergic asthma ,
allergic rhinitis,conjunctivitis (hay fever),
Urticaria(hives), vernal conjunctivitis

Family history : eye problems other than just needing glases ? familial
ocular(retinal, corneal , glaucoma,cataract) and systemic diseases-thyroid ,
DM, HTN, hereditary disorders, atopy
*inability of the patient to provide information about the family medical
background should not be construed as negative family history instead

incomplete or lacking should reflect without examining the family members

Social history - personal protective equipment (safety glasses and goggles),

Tobacco, alcohol use, sexual history , tattoos, body piercing and

occupational history - patients jobs and hobbies- it is vital

* question should be pursued in a non judgemental way -respect for privacy and should not be
revealed to third parties except required by law and with patients permission.

* review of systems - diseases

EXAMINATION -

 Visual activity 
 Color vision
  Eye movements/diplopia
  Visual fields
  Pupil reflexes
 General and external eye appearances - ectropion , entropion, skin laxity,
 scars, trauma evidence
 Conjunctiva - color , blood vessel injection, swelling / oedema
 (chemosis)
  Cornea - clarity(should be stained with fluorescein and examined under a
 cobalt blue light for epithelial defects) 
 Anterior chamber- slit lamp / pen torch- hypopyon/hyphaemaP
 Pupil -size,shape,symmetry,reflexes
  Direct ophthalmoscope-fundus examination,red reflex to check for lens opacity
  Trigeminal nerve assessment-corneal sensation and function of facial nerve - eye closure