This document contains a sample case assessment from an uveitis outpatient department. It provides demographic information, chief complaints, ocular and medical history, examination findings, and assessment for a 51-year-old female patient presenting with recurrent redness and eye pain in the right eye for 15 days. On examination, the right eye shows conjunctival congestion, stromal edema with deep vessels in the cornea, cells in the anterior chamber, and posterior synechiae of the iris. The left eye also demonstrates similar findings but to a lesser degree.

1. Presented by – Prarthana Buragohain

2.  A good history commonly leads to a
diagnosis
 Helps you focus on examination
 Indicates when/what investigation are
needed
 Helps determine the functional impact of the
condition

3. General out patient department history taking
procedure
Demographic data-
- Name (for identification , filing system,
friendly)
- Age (age related disease eg- children-
congenital,old-senile disease)
- Gender (gender related disease)
- Address (endemic disease, social status )
- Occupation (occupation related disease)

4. Chief complain (c/o) In patient’s language ( in which over
confortable language he/she want to speak)
 Duration of complaint
 If it is involving one or both eyes?
 Any associated symptoms?
 Any similar problem before?
 Previous medical advice and medication
PTO.

5. There are two types of complain:-
1. Visual complaints:-
Sudden loss of vision, diminuation of vision ,
blurring of vision , photophobia.
2. Non visual complaint:-
Discharge , pain , itching , swelling

6. Spectacle history
 Is he/she using any spectacle
 If using since how many Days/months/years
he/she using the spectacle
Also check out present glass prescription
by neutralisation of lens ( by manually or
automated eg-lensometer )
glass history should must be taken
if he/she is complaining of blurring of vision
or diminishing of vision.

7. Ocular history
 We should ask the patient if similar ocular
related problem have existed before
 Previous eye surgery or eye injury
 Chronological order of major illness and
major problem
 Ask the use of ocular medication if he/she is
presently using.

8. Systemic history
• We should ask the patient about any systemic
health related history is existing or not
Eg- diabeties – if patient have diabeties and it may
lead to diabetic retinopathy ( which indicate
blurring of vision and related to thickening of the
retina with 500 micron)
• Hypertension
• Thyroid
• Asthama
• Heart disease
• Malingant diseases

9. Contact lens history
 If patient using contact lens history we have
to note it up with asking of which company
contact lens you are using

10. Systemic medication history
 Of what type medicine you are using to cure
the systemic disease

11. Drug allergy disease history
 We should ask the patient about you have
any allergy to the drugs

12. Family history
 We should ask the patient whether his mother,
father , grandfather, grandmother have these
disease
 Glaucoma
 Squint
 Myopia
 Cataract
 Poor vision
You should also ask about your family systemic
history

13. Birth history
 Birth history is taken for children only
The history should be proceeds as if baby
birth is premature or forcep delivery or low
birth weight.

14. Social history
We should ask if patient is consuming
1. Smoking
2. Alcohol
3. Or any occupation or home circumstances
problem

15. All these are ask to each patient to each
ocular department.
Certain complaint of ocular cases are follows

16. Catract out patient dept history taking
procedure- senile cataract case
 Demographic data – it is seen in old patient
usually above the age of 45 years
 Presenting complain- 1. gradual loss of vision
2. May be associated with coloured halos , glare
 History of present illness
h/o of radiation, injury to affected eye, diabetic
mellitus,steroid intake,
 To rule out diseases affecting surgical
treatment eg diabeties mellitus , hypertension.

17. Uvea out patient h/o taking procedure –
acute iridocyclitis
 Demographic data
 Presenting symptoms- moderate to servere
pain , photophobia,
watering,redness,diminution of vision in
sudden onset.
 h/o of present illness- h/o of allergic
condition like brochial asthama, hay fever,
allergic skin condition
 h/o of joint pain to rule out rheumatoid
disease

18.  h/o of trauma to eye
 h/o of sinusitis
 Past history
h/o of similar attacks in past
h/o of systemic infection eg
tubercolosis,leprosy,syphills etc
h/o of non infectious disease eg collagen
disorder, gout etc
h/o of allergic and autiimmune disorder

19. taking – corneal opacity and pterygium
Corneal opacity-
 Demographic data
 Presenting symptoms- whitish scar, causing defective
vision
 History- history of trauma to eye
Pterygium:-
 Demographic data
 Age and sex- more common in male than female
occur in middle age
 Presenting symptoms
PTO.

20.  Extra growth on the cornea
 Slight irritation or foreign body sensation
 Diminuation of vision due to astigmatism
procced by traction on the cornea
 Diplopia may occur due to limitation of
ocular movement

21. Glaucoma out patient dept history taking
procedure- primary open angle
glaucoma
 Demographic data- usually affects 1 to 100 of
general population above the age of 40 age .
The disease is usually bilateral.
 presenting symptoms –1. mild headache
2. Difficulty in reading
3. Occasionally patient notice a defect in visual
field(scotoma)
4. In late stages patient complain of delayed dark
adaptation
 Family history is also taken

22. Strabismology out patient dept history
taking procedure
 Demographic data
 Presenting symptoms-patients presents with
deviation of one eye
 h/o of present illness-
1. Age of onset
2. Mode of onset , sudden or gradual
3. Precipitating factor such as systemic illness,
trauma,
4. h/o of diplopia
5. Birth history is important in early childhood onset
deviation and h/o of glasses
 Family history is important in case of stabismus

23. Case assesment from uvea out patient
department
Mr no- 1283965
Name- Vdaya chndrika
Age -51 years sex- female
History- nil
Systemic disease – nil
Complaint- c/o recurrent redness since 15 days in
right eye
c/o eye pain with pricking sensation since 15 days
h/o using glasses from 2 months

24. Acceptance
OD- +0.75DSph/-1.00Dcyl*75 6/9
OS- plano/ 6/6 add= +2.00Dsph
Vision Distance Near
OD OS OD OS
UNAIDED 6/18 6/6
PINHOLE 6/9
BEST CORRECT 6/9 6/6 6/6RS 6/6RS

25. OLD GLASSES:-
OD- +2.00DSph
OS- +2.00Dsph
slit lamp examination
OD OS
Lid normal normal
Conjunctiva congetion congetion
more inferior more
inferior

26. Cornea inferior stroma inferior stroma
edema with deep with deep
vessels vessels
Anterior 1+cells cell 0.5
Chamber
iris posterior posterior
synechia synechia
Pupil p.s at 4o clock posterior
synechia inferior

27. Fundus CD 0.3 , CD 0.3’
HDRR , FR+, HDRR, FR+
Rest nornal Rest normal
vitreous cells + inferior
snow ball