Case Report Example
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 –
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 –