Download Dear Notetaker:

CLE 162.1 – Course I
Notetaker: Mallory McLaughlin
Date: 9/5/2012, 1st hour
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Exam is on Monday. Dr. To will only be answering questions until Sunday at 8pm about the
exam.
Patient Case Histories
There were five patients’ chief complaints presented. The class asked Dr. To questions related to
the steps of case histories (found in the notes) to find out everything we need to know to form a
 History of Present Illness (HPI)
 What the chief complaint (CC) is most likely due to (ocular health, optics/refractive error,
or binocular vision/functional vision)
 What problem related tests we would perform on the patient.
Note 1- The general format for an HPI write-up is detailed in Dr. To’s notes on pg 16 and is as
follows:
HPI: (frequency and duration), (onset), (location,) (association/modifying
factors), (relief), (quality/description)
Example- CC: “blurry vision”. HPI: constant, 6 months, gradual, OU, better with CL vs
SRx, relief with squinting, 5/10
Note 2- More details on what the CC is mostly likely due to (ocular health, optics/refractive
error, or binocular vision/functional vision) are found on pg. 3 of the first handout
Note 3- The classifications of questions that should be asked to the patient during the Case
History is also detailed in the notes but follows this general guideline
1. Social history
a. Demographics
b. Visual demand
c. Lifestyle
d. Relationships
2. Chief complaint (CC)
3. History of present illness (HPI)
a. FOLDARQ
4. Ocular History
a. Refractive history
b. Ocular health history
c. Ocular medications
5. Patient Medical History (PMH)
a. Past/current illness and disease
b. Past/current surgery or trauma
c. Review of symptoms
d. Systemic medications
e. Allergies
6. Family History
a. Ocular (FOH)
b. Medical (FMH)
7. Wrap up
LECTURE
Case 1Bill G 55 YO CM
CC- “blurry vision”
55 year old Caucasian male that complains of blurry vision
CLE 162.1 – Course I
Notetaker: Mallory McLaughlin
Date: 9/5/2012, 1st hour
Page2

Questions askedo When did your problems start?- about 5 months ago
o It it in distance or up-close?- intermediate
o Last time you were at your primary care physician?- 3 months ago
o Any diabetes?- no
o Do you wear reading glasses- yes bifocals and they are 1 year old
o Do you do a lot of computer work?- yes 14 hours per day.
o Do you take your glasses off when you do computer work?- no I just struggle
until I can see things clearly
o Is it a progressive bifocal- yes
o Any head aches?- no
o Do you have dry eyes- no
o Do you see double- no
o When was your last eye exam- 1 year ago
o Is it both eyes or one eye- both
o Is your vision blurry throughout the day or only at a particular time?- only when I
use the computer
o What relieves the blurry vision- if I stop working or increase magnification on my
screen it helps
CC: “blurry vision” HPI: OU, with habitual SRx, gradual onset, 8—14 hours/day, while at
computer, (+) relief with stopping work, increasing magnification on screen
Most likely due to: (binolocular, refractive, or ocular health)- refractive
Problem related tests- visual acuity (near and intermediate) and refraction
Case 2Beyonce K. 31 YO AAF
CC: “Blurry vision”
 When did it start- 3 days ago
 Do you wear glasses or contacts?- no
 How did it start- I was on my yacht and it was really windy out and my vision just got
blurry
 Do you feel like something is in your eye- no
 Seasonal allergies- no
 Is all vision blurry, just close up or far?- distance and far. It happens intermittently.
 Different at different times of day- happens when I’m out yachting or later in the day
 Can you do anything to relieve the symptoms- yes blinking and I use artificial tears
 Have you notice increased eye watering- yes
 History of glasses in the family- nope
 Have you had dry eyes before- nope
 Do you take vitamins- yes
 Could you be pregnant- yes
CC: “blurry vision” HPI: OU, gradual, intermittent, 3 days ago, in pm, while on yacht, (+)
relief when blinking, ATS, 6/10
Most likely due to: ocular health
Problem based tests: VA (near and distance) and Biomicroscopy to look at tear layer for dry eye
issue
CLE 162.1 – Course I
Notetaker: Mallory McLaughlin
Date: 9/5/2012, 1st hour
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Case 3Sidney C. 25 Y.O. CM
CC: “floaters”
 Any injuries to the eye- yes, I got in a fight last night
 Is your vision blurry- nope just floaters
 Did the floaters start last night?- yes
 Are you seeing flashes?- no
 Double vision- no
 Is it in both eyes- only in right
 Where did you get hit at- right side of the face
 Do they move when you move your head- yes
 Are they small in diameter or are they wavy like- they are various sizes
 Is there any pain- no
 Light sensitivity- no
 Constant or do they come and go?- when I look at them they disappear but If I’m not
looking at them they’re almost always around
 Vomitting or dizziness- no
 Concussion- no
 What’s your occupation- hockey player
CC: “floaters”. HPI:OD, sudden, x 1 day, intermittent, after fight, no relief, (-) flashes, (-)
concussion,
Most likely due to: Ocular health
Problem related tests- binocular indirect opthlamoscopy
Case 4Morgan F. 75 Y.O. AAM
CC: “Blurry Vision”
 Duration- about a year
 Is it up close or distance- both
 Do you wear glasses- only reading glasses
 Is it in one or both eyes- both eyes
 Is it worse at any particular time of the day- not really
 Any cataracts surgery- nope no surgery before
 How is your night vision- can’t drive at night anymore because the glare from the street
lights is too strong
 Do you have family history of cataracts- yes (but we all have family history of cataracts)
 Does your family have a history of glaucoma- paternal grandfather had glaucoma
o Blindness in your family?- yes my grandfather went blind at age 65 (blindness
would be a sequelae of diabetes. A sequelae is a consequence. ex- concussion or
coma)
o Did he go blind from the glaucoma- yes
 Any macular degeneration in the family- no
 Diabetes in the family- yes I have diabetes
o Is it controlled diabetes- yes I take insulin and diet
CLE 162.1 – Course I
Notetaker: Mallory McLaughlin
Date: 9/5/2012, 1st hour
Page4
o A1C (indicates control over diabetes)- 6 (5 and 6 are pretty good numbers as far
as control) (average over 3 months)
o What was your blood sugar today- this morning it was 75 (direct measurement at
that particular point in time)
o Does the range of your blood sugar vary dramatically? What is high and low
point?- didn’t answer this question
o How often do you visit your primary care doctor- 2 times per year
o Any changes in medication in the last few years- no
o How often do you measure your blood sugar- every morning
 What’s your blood pressure- 120/79
o Do you take any medication for blood pressure- yes a water pill
o History of hypertension in the family- yes I have it and so does my father
o How often do you measure your blood pressure- every morning
 Any recent changes in your health this year- yes I had a stroke
o Do you see a neurologist- I do follow up with my neurologist
o How long ago did you have the stroke- 1 year
o Vision changes- no
 Is there any one in your family with eye diseases or medical conditions I should be aware
of- both my parents had cataracts and my sister had sickle cell disease
o Have you been tested for sickle cell- yes I don’t have it
 Are you a smoker?- no
 Drink- no
 Drugs- no
 STDs- no
 Diet- eat a fairly healthy diet, try to get 5 servings of veggies every day
 What do you do with your eyes all day- I’m an actor. I like to read in my spare time
 Eye drops- no
 Allergies- none
CC: “blurry vison” HPI: OU, gradual onset, x1 year, distance and near, constant, (+) difficulty
reading newspaper, (+) glare with lights, no relief 7/10
LEE: 1 year ago
LME: 3 months ago
Habitual SRx: reading only
PMH: (+) DM x 15 years, treated with insulin and diet, LBS: 75 mg/mL. H1BAC: 6, sees PCP
2x/year, h/o stroke, no visual sequelae
(+) HTN x 5 years, treats with “water pill” LBP: 120/79 this am. Measures qd
POH: unremarkable
FMH: (+)Glc PGF, went blind at age 65. (+) cat, mother and father. (+) sickle cell disease:
sister. All: NKMA, NKDA
Due to: ocular health
Problem related tests- VA(distance and near), DFE- Biomicroscopy, Glare test (BAT)
CLE 162.1 – Course I
Notetaker: Mallory McLaughlin
Date: 9/5/2012, 1st hour
Page5
Case 5Danielyn B 5Y.O. CF
CC: “inwards eye turn”
 Who are you- her father
 When did you notice eye turn- when she was 1, 4 years ago, started a little at first and
then became more and more apparent
 Which eye- always left eye
 Is it constant or intermittent- its constant, always turned in
 Any surgeries- nope
 Any history of trauma- no
 When was the last time she went to the optometrist, has she been seen before- yes
o Patchy- no
o Atropine drops- no
 Glasses- yea but she doesn’t like to wear them so I don’t make her
 When was the last time she wore them- 1 year ago
 Headaches- no
 Performance at school- preschool was fine
 Double vision- not that she tells me
 Genetics- I (her father) also has an eye turn
 Relief?- didn’t answer this question
 Quality?- any pain, does she complain about it? No but other kids make fun of her
 Does she know how to read- she’s learning
 Was she full term- yes 39 weeks
o C- section –yes
o Oxygen- nope
o Complications- no
 Developmental delays or therapies- no delays but going through speech therapy
 Was mother on drugs or meds during pregnancy- uncertain
 Any known allergies- penicillin and gluten
 Overall health- good

CC: “eye turn”, HPI: OS, since 1 year, gradual at first, now constant, same magnitude, concern
over cosmesis, (-)wear previous SRx, (-) reported diplopia, (-) relief
Birth History: 6lbs 2 oz, 39 weeks, (-) O2 required, (+) c- section, (-) complications, (-)
developmental delays, (+) speech therapy, going into kindergarten
LEE: 1 year ago
LME: 1 month ago
PMH: unremarkable
FOM: (+) strabismus- father
All: PCN, Gluten
Most likely due to: binocular vision
Problem related tests: VA, Cover test, stereopsis, near testing
CLE 162.1 – Course I
Notetaker: Mallory McLaughlin
END OF TESTING MATERIAL FOR MONDAY
Date: 9/5/2012, 1st hour
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