National Medical University named after A.

Bogomoletz

Ophthalmological department

Chief of department: Zhaboiedov D.G.

MD, professor.

Curator of the group: ____________________

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CASE REPORT

Patient’s name Olatunji Tope

Age 21
Diagnosis Uveitis

Student Olatunji Oluwagbemisoke Esther

Faculty Medicine
Course 4 Group 20

Kyiv - 2020
 I. PASSPORT DATA
Name Olatunji Tope__________________________________________________________
Date of birth «12__»__________12 1999______ Age _________21 Sex Female
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Date of admission06. 12. 2020 , Urgency _____________________________
Hospital University teaching hospital ______________________
Profession Teacher___________________________________________________

II. INTERROGATION
Complaints on the afternoon of 6 December, 2020, Tope came into the admission room with
th

complaints of pain of eye, increased sensitivity to light, redness of eye and blurred vision.
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Anamnesis morbi
Site; Right eye
Onset; acute
Character;painful
Association; none
Course; recurring.
Anamnesis vitae (Present history, Past history, Personal and professional history)
Tope had previously been diagnosed with myopia(bilateral) when he was 19 years old during a routine
examination. He doesn’t wear glasses but he wears contacts(rapid permeable contact lenses with
dioptric power of -2.00
He has done no ocular surgery and he hasn’t any recollection of any ocular injuries

Past medical history

He had no history of autoimmune diseases
He hasn’t undergone any surgeries
Drug history
Once a day multivitamin
Gummy herbal capsules 1 capsule a day
Family history
No history of blindness, glaucoma, cataracts, lazy eye and macular degeneration and retinal
detachment in his family. His father has stress-induced hypertension
Social history
Occupation; Software programmer
Marital status;Single
Dietary restrictions; Lactose intolerance and gluten sensitive
He doesn’t abuse drugs
He regularly gyms and goes safari surfing
Allergic history
He has an allergic sensitivity to penicillin and seasonal rhinitis.

III. STATUS PRAESENS OBJECTIVUS COMMUNIS

General state Weight of 77kg, Height of 170cm, No significant weight loss, and no night chills.
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Skin, Locomotive systems Normal
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Cardiovascular system Heartrate of 72mmhg Blood pressure of 109/87 mmhg
No arrhythmia noticed
Angiography not included
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Respiratory system respiratory rate of 18/min
No bronchitis, pneumonia, asthma, emphysema and tuberculosis
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Digestive system Normal He had previously been diagnosed with mild peptic ulcer.

Nervous system, Normal

_ Endocrine glands
No underlying hormonal imbalance is suspected
Hormone function test especially of T3 and T4 is within normal range

Urogenital system Normal

Otolaryngological; No hearing loss

No sinusitis
No laryngitis

Yes
 VI. LOCAL OPHTHALMOLOGICAL STATE

# Item Right Eye (OD) Left Eye (OS)

1 Visual acuity (without 0.5 0.5
correction, with correction)
2 Clinical refraction -3.0 -2.75

3 Peripheral vision
(by a control method or on a
perimeter)

4 Colour vision. Normal Normal

5 Binocular vision. Normal Normal

6 Dark adaptation Normal Normal

7 Eye fissure (position, sizes)

Elliptical shape slightly increased in dimension in OD.

8 Eyelids (position, growth of

cilia)

9 Lacrimal organs (state, Normal in state and functioning Normal in state and functioning
ability for drainage, tests).

10 Eyeball (position, mobility, Normal position in orbit , Normal Normal position in orbit, Normal
convergence), motility motility

11 Intraocular pressure 13mmHg (Goldman) 14mmHg (Goldman)

12 Conjunctiva ( colour,
mobility, vessels),
13 Cornea (transparency,
sensitiveness, sizes,
curvature)
Red, inflamed, circumorbiyal Red and inflamed
Presence of keratin precipitates , Presence of keratin precipitates,
small and fine small and fine
# Item Right Eye (OD) Left Eye (OS)
14 Limbus (width, changes)

15 Sclera (colour, vessels) White, non icteric White, non icteric

16 Anterior chamber (state of Inflammatory cells present, Inflammatory cells present,

fluid, depth, sizes) moderate to marked flare moderate to marked flare

17 Iris and (colour, picture, form) Slightly hazy, nodules absent, no Slightly hazy, nodules absent and
structural abnormalities no structural abnormalities
18 Pupil (direct and concord reaction Size: 2.3mm Size: 3.4mm
on light, reaction on convergence Equality;1.1mm Equality;1.1mm
and accommodation) Shape; slightly eccentric Shape; slightly eccentric
Response to light; normal Response to light; normal
19 Ciliary body (pain, Inflamed Inflamed
sensitivity)

20 Lens of the eye Slightly hazy, normal position Slightly hazy, normal position
(transparency, position)

21 Vitreous body (transparency) Clear, not hazy Clear, not hazy

22 Reflex from Eye fundus Normal color, appropriate Normal color, appropriate
(color, brightness, regularity) brightness, normal regularity brightness and normal regularity

23 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 Normal _______ Optic nerve disk Normal _

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Retinal vesselsNormal_________ Retinal vessels Normal ______
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Central part Normal___________ Central part Normal __________
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Periphery Normal _________ Periphery Normal ____________
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 VII. INFORMATION OF ADDITIONAL EXTERNAL EXAMINATIONS
AND SPECIAL RESEARCHES

General examination
Blood Normal
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Urine Normal______________________________________________________________________
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X-ray, MRT :Normal_______________________________________________________________
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UltrasonicNormal _____________________________________________________________
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Consultations (therapeutist, otorhinolaringologist, neurologist, etc.):
Opthamologist
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Other researches depending on pathology (conclusions).
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Fluorescent test Normal
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Shirmer’s test Normal
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Diurnal tonometry, mm Hg: not useful in the diagnosis of the disease

Day 1 2 3 4 5 6 7 8 9 10

OD

OS
 VIII. DIAGNOSIS
Ground of diagnosis. Differential diagnosis.
Diagnosis;Uveitis
Differential diagnosis; Conjuctivitis, Keratitis, intra-ocular foreign body.
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Clinical diagnosis.
Non-granulomatous Anterior Uveitis ( Unilateral)
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 IX. TREATMENT
(surgical, medicinal, local and systemic)
Surgical treatment ___________________________________________________________________
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Medicinal _________________________________________________________________________
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Prescriptions:
Rp.:
Atropine 1% 5ml
I drop expected 3 times daily with intervals of
Rp.: Prednisolone acetate 1%
5-6 hours
Drop every 2 hours into affected eye
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Rp.: ________________________________ Rp.: ________________________________

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Physiotherapy Use sunglasses when outside __________________________________

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Other _____________________________________________________________________________
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 X. VISUAL (Functional) PROGNOSIS AND RECOMMENDATIONS
Prompt initiation of treatment may shorten the duration of the attack, There is a tendency of a
reoccurrence_________________________________________________________________
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Student’s signature _________________

Signature of curator _________________