Case Report Example

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  • Topic: Eye examination, Refractive error, Myopia
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  • Published : August 11, 2011
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Centro Escolar University
COLLEGE OF OPTOMETRY

CLINIC 1
S.Y. 2011 – 2012

Clinician's Name: Year & Section: ODP3A
Patient's Name:

CASE # 1 EVALUATION

SUBJECTIVE

The patient is a 19year-old male Information Technology student of Centro Escolar University. His Gait and Facial Symmetry were good and the head position and speech is normal. He talks clearly and has no unpleasant odor. His reason for visit is to have an eye check up.

He complains of constant blurring of vision at far with no associated complains. He is neither a spectacle wearer nor contact lens user
He is not taking Multivitamins.

OBJECTIVE

PRELIMINARY EXAMINATION
• VISUAL ACUITY
A. Unaided at Distance:
1. OD: 20/25
2. OS: 20/25
3. OU: 20/25
B. Unaided at Near
1. OD: J3
2. OS: J3
3. OU: J2
C. OD is the dominant eye and she uses right hand when writing

• OLD RX
None

• COVER TEST
A. Without Rx
1. Exophoria at Distance
2. Exophoria at Near

• CORNEAL REFLEX TEST
A. OD Centric
B. OS Centric

• DIPLOPIA TEST
A. Physiologic Diplopia is present
• NPA
1st Trial 2nd Trial 3rd Trial

A. OD 13.33 13.33 13.33
B. OS 11.42 13.33 11.42
C. OU 13.33 13.33 13.33

• NPC
1st Trial 2nd Trial 3rd Trial

4.5/10cm 4.5/10cm 4.5/10cm

• Pupil size for OU is 5.0mm with equal and active responses to light (3+)
and accommodation (2+)

• MOTILITY TEST

A. Version – Smooth, Accurate, Full & Extensive
B. Duction – Smooth, Accurate, Full & Extensive
C. Saccades – Fast and Accurate

II. EXTERNAL EXAMINATION – SLE
OU is Normal

III. INTERNAL EXAMINATION – Direct Ophthalmoscopy
OU findings are Normal (No significant findings)

IV. REFRACTION
A. Keratometry
VMHMMIRESAC
OD 44.000 43.750 Clear & Regular -0.250Dcyl x 180
OS 44.250 44.250 Clear & Regular 0

B. Objective
1. Static Retinoscopy ( Net )
OD: -1.50Dsph = -0.25Dcyl x 90
OS: -1.00Dsph = -0.7 5Dcyl x 180

2. Dynamic Retinoscopy
OD: +0.50Dsph = -0.25Dcyl x 90
OS: +0.75Dsph = -0.75Dcyl x 180

3. Dynamic Retinoscopy
OD: +0.25Dsph = -0.25Dcyl x 90
OS: +0.50Dsph = -0.75Dcyl x 180

C. Subjective
1. VT # 7 Findings
OD: -0.75Dsph20/20 BCVA
OS: -0.75Dsph20/20 BCVA
OU20/20 BCVA

V. PHOROMETRY
|DISTANCE |NEAR | |PHORIA | |Lateral |Orthophoria |Orthophoria |Lateral |6Exophoria |4Exophoria | |Vertical |Orthophoria |Vertical |Orthophoria |

|VERGENCE | |BO |8 |16/10 |BO |6 |16/8 | |BI | | |BI...
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