Opthalmology Long Cases Notes:-
PART 1: The Clinical Proforma & Sample
Cases
1. THE UNIVERSAL LONG CASE TEMPLATE
(Write this exact sequence for every long case in your record book and exam)
Date: [Exam Date]
1. Identification Data
• Name:
• Age/Sex:
• Address/Place:
• Occupation:
2. Presenting Complaints
• (Primary symptom + duration in chronological order)
3. History of Present Illness (HOPI)
• Onset: Gradual / Sudden
• Course: Progressive / Non-progressive
• Pain: Present / Absent
• Associated visual phenomena: Haloes, glare, flashes (photopsia), floaters, distorted
vision, diplopia.
• Associated physical symptoms: Redness, watering, discharge, headache,
photophobia.
• Negative History: No history of trauma, no history of drug intake causing visual
complaints.
4. Past History
• Ocular history: Spectacle use, previous ocular surgery, trauma.
• Medical history: Diabetes Mellitus (DM), Hypertension (HTN), Bronchial Asthma
(BA), Coronary Artery Disease (CAD). (Include duration and medications).
• Drug history / Allergy: Present / Absent.
5. Personal History
• Diet, sleep, bowel & bladder habits, addictions (smoking/alcohol).
,6. Family History
• Similar illness, familial DM/HTN, glaucoma, blindness.
EXAMINATION
7. General Examination
• Patient conscious, oriented, cooperative.
• Moderately built and nourished.
• PICCLE: No pallor, icterus, cyanosis, clubbing, lymphadenopathy, or edema.
• Vitals: BP: / mmHg, PR: ___/min.
8. Systemic Examination
• CVS / RS / CNS / PA: Within normal limits.
OCULAR EXAMINATION
9. Head Posture and Face
• Head posture: Normal (No head tilt/face turn/chin elevation).
• Facial symmetry: Normal.
10. Ocular Alignment & Motility
• Ocular posture: Eyes orthophoric. No proptosis, ptosis, strabismus, or nystagmus.
• Extraocular movements: Full in all directions (uniocular and binocular).
11. Visual Acuity (Snellen)
• RE: ___ | LE: ___
12. Field of Vision (Confrontation)
• RE: Normal | LE: Normal
13. External Examination / Adnexa
• Eyebrows: RE: Normal | LE: Normal
• Lids & Adnexa: RE: Normal | LE: Normal (No entropion/ectropion/trichiasis)
• Lacrimal Apparatus: * ROPLAS: Negative (both eyes).
• Conjunctiva: RE: Normal | LE: Normal
• Sclera: RE: Normal | LE: Normal
14. Anterior Segment Examination (Torch/Slit lamp)
• Cornea: RE: Clear, sensation normal | LE: Clear, sensation normal
, • Anterior Chamber: RE: Normal depth, clear | LE: Normal depth, clear
• Iris: RE: Colour & pattern normal | LE: Colour & pattern normal
• Pupil: RE: Size (mm), shape, direct & consensual reflex | LE: Size (mm), shape,
direct & consensual reflex
• Lens: RE: _______ | LE: _______
15. Intraocular Pressure (Digital/Applanation)
• RE: Normal digitally | LE: Normal digitally
16. Posterior Segment (Fundus)
• RE: _______ | LE: _______
17. SUMMARY
• (Concise paragraph combining demographics, key HOPI, and striking exam
findings).
18. DIAGNOSIS
• (Eye + Condition + Systemic status).
19. DIFFERENTIAL DIAGNOSIS
• (If applicable).
20. INVESTIGATIONS
• (Routine + Ocular specific).
21. TREATMENT / MANAGEMENT
• (Medical / Surgical).
22. COMPLICATIONS
• (If left untreated).
23. PROGNOSIS
• (Visual outcome expectation).
2. DETAILED SAMPLE LONG CASES
CASE 1: IMMATURE SENILE CATARACT (RE) + PSEUDOPHAKIA (LE)
, 1. Identification Data
• Name: Ramanan
• Age/Sex: 62 years / Male
• Address/Place: Thiruvananthapuram
• Occupation: Retired Clerk
2. Presenting Complaints
• Painless, gradual, progressive defective vision in the right eye for 1 year.
• History of surgery for defective vision in the left eye 1 year back.
3. History of Present Illness
Patient was apparently normal one year back. He developed diminution of vision in the right
eye, which was gradual in onset, progressive, and painless. He complains of glare while
driving at night. There is no history of redness, watering, photophobia, coloured haloes,
floaters, or diplopia. There is no history of trauma or ocular drug intake. Left eye vision is
currently satisfactory following cataract surgery done 1 year ago.
4. Past History
• Ocular: Surgery for defective vision in left eye – 1 year back. Uses reading glasses.
• Medical: Known case of Type 2 DM for 5 years on oral hypoglycemics. No
HTN/BA/CAD.
• Allergy: No known drug allergies.
5. Personal History
• Normal diet, sleep, bowel, and bladder habits. Non-smoker, non-alcoholic.
6. Family History
• No significant history of blindness or glaucoma in the family.
EXAMINATION
7. General Examination
• Patient conscious, oriented, and cooperative. Moderately built and nourished. No
pallor, icterus, cyanosis, clubbing, edema, or lymphadenopathy. BP: 130/80 mmHg.
PR: 76/min.
8. Systemic Examination
• CVS/RS/CNS/PA: Within normal limits.
OCULAR EXAMINATION
PART 1: The Clinical Proforma & Sample
Cases
1. THE UNIVERSAL LONG CASE TEMPLATE
(Write this exact sequence for every long case in your record book and exam)
Date: [Exam Date]
1. Identification Data
• Name:
• Age/Sex:
• Address/Place:
• Occupation:
2. Presenting Complaints
• (Primary symptom + duration in chronological order)
3. History of Present Illness (HOPI)
• Onset: Gradual / Sudden
• Course: Progressive / Non-progressive
• Pain: Present / Absent
• Associated visual phenomena: Haloes, glare, flashes (photopsia), floaters, distorted
vision, diplopia.
• Associated physical symptoms: Redness, watering, discharge, headache,
photophobia.
• Negative History: No history of trauma, no history of drug intake causing visual
complaints.
4. Past History
• Ocular history: Spectacle use, previous ocular surgery, trauma.
• Medical history: Diabetes Mellitus (DM), Hypertension (HTN), Bronchial Asthma
(BA), Coronary Artery Disease (CAD). (Include duration and medications).
• Drug history / Allergy: Present / Absent.
5. Personal History
• Diet, sleep, bowel & bladder habits, addictions (smoking/alcohol).
,6. Family History
• Similar illness, familial DM/HTN, glaucoma, blindness.
EXAMINATION
7. General Examination
• Patient conscious, oriented, cooperative.
• Moderately built and nourished.
• PICCLE: No pallor, icterus, cyanosis, clubbing, lymphadenopathy, or edema.
• Vitals: BP: / mmHg, PR: ___/min.
8. Systemic Examination
• CVS / RS / CNS / PA: Within normal limits.
OCULAR EXAMINATION
9. Head Posture and Face
• Head posture: Normal (No head tilt/face turn/chin elevation).
• Facial symmetry: Normal.
10. Ocular Alignment & Motility
• Ocular posture: Eyes orthophoric. No proptosis, ptosis, strabismus, or nystagmus.
• Extraocular movements: Full in all directions (uniocular and binocular).
11. Visual Acuity (Snellen)
• RE: ___ | LE: ___
12. Field of Vision (Confrontation)
• RE: Normal | LE: Normal
13. External Examination / Adnexa
• Eyebrows: RE: Normal | LE: Normal
• Lids & Adnexa: RE: Normal | LE: Normal (No entropion/ectropion/trichiasis)
• Lacrimal Apparatus: * ROPLAS: Negative (both eyes).
• Conjunctiva: RE: Normal | LE: Normal
• Sclera: RE: Normal | LE: Normal
14. Anterior Segment Examination (Torch/Slit lamp)
• Cornea: RE: Clear, sensation normal | LE: Clear, sensation normal
, • Anterior Chamber: RE: Normal depth, clear | LE: Normal depth, clear
• Iris: RE: Colour & pattern normal | LE: Colour & pattern normal
• Pupil: RE: Size (mm), shape, direct & consensual reflex | LE: Size (mm), shape,
direct & consensual reflex
• Lens: RE: _______ | LE: _______
15. Intraocular Pressure (Digital/Applanation)
• RE: Normal digitally | LE: Normal digitally
16. Posterior Segment (Fundus)
• RE: _______ | LE: _______
17. SUMMARY
• (Concise paragraph combining demographics, key HOPI, and striking exam
findings).
18. DIAGNOSIS
• (Eye + Condition + Systemic status).
19. DIFFERENTIAL DIAGNOSIS
• (If applicable).
20. INVESTIGATIONS
• (Routine + Ocular specific).
21. TREATMENT / MANAGEMENT
• (Medical / Surgical).
22. COMPLICATIONS
• (If left untreated).
23. PROGNOSIS
• (Visual outcome expectation).
2. DETAILED SAMPLE LONG CASES
CASE 1: IMMATURE SENILE CATARACT (RE) + PSEUDOPHAKIA (LE)
, 1. Identification Data
• Name: Ramanan
• Age/Sex: 62 years / Male
• Address/Place: Thiruvananthapuram
• Occupation: Retired Clerk
2. Presenting Complaints
• Painless, gradual, progressive defective vision in the right eye for 1 year.
• History of surgery for defective vision in the left eye 1 year back.
3. History of Present Illness
Patient was apparently normal one year back. He developed diminution of vision in the right
eye, which was gradual in onset, progressive, and painless. He complains of glare while
driving at night. There is no history of redness, watering, photophobia, coloured haloes,
floaters, or diplopia. There is no history of trauma or ocular drug intake. Left eye vision is
currently satisfactory following cataract surgery done 1 year ago.
4. Past History
• Ocular: Surgery for defective vision in left eye – 1 year back. Uses reading glasses.
• Medical: Known case of Type 2 DM for 5 years on oral hypoglycemics. No
HTN/BA/CAD.
• Allergy: No known drug allergies.
5. Personal History
• Normal diet, sleep, bowel, and bladder habits. Non-smoker, non-alcoholic.
6. Family History
• No significant history of blindness or glaucoma in the family.
EXAMINATION
7. General Examination
• Patient conscious, oriented, and cooperative. Moderately built and nourished. No
pallor, icterus, cyanosis, clubbing, edema, or lymphadenopathy. BP: 130/80 mmHg.
PR: 76/min.
8. Systemic Examination
• CVS/RS/CNS/PA: Within normal limits.
OCULAR EXAMINATION
