Eyes

#Eyes

S: Subjective

History: 
Right eye: 
(-) vision change
(-) vision loss
(-) floaters
(-) pain
(-) irritation
(-) itching
(-) redness
(-) discharge
(-) watering
(-) foreign body sensation
(-) other ->

Left eye: 
(-) vision change
(-) vision loss
(-) floaters
(-) pain
(-) irritation
(-) itching
(-) redness
(-) discharge
(-) watering
(-) foreign body sensation
(-) other ->

Symptom Development: 
- Onset: 
- Variation: 
- Aggravating factors: 
- Relieving factors:

O: Objective

Examination: 
Right eye: 
(-) conjunctival injection
(-) pterygium
(-) discharge
(-) lid swelling
(-) lid mass
(-) blepharitis
(-) ectropion
(-) entropion
(-) ingrowing lashes
(-) conjunctival foreign body
(-) corneal ulcer/abrasion
(-) corneal foreign body
(-) hyphaema
(-) Other ->

Left eye: 
(-) conjunctival injection
(-) pterygium
(-) discharge
(-) lid swelling
(-) lid mass
(-) blepharitis
(-) ectropion
(-) entropion
(-) ingrowing lashes
(-) conjunctival foreign body
(-) corneal ulcer/abrasion
(-) corneal foreign body
(-) hyphaema
(-) Other ->

Vision tests:

- Visual acuity, distance (Snellen chart):
  - Uncorrected: Right ?/6, Left ?/6
  - Corrected: Right ?/6, Left ?/6
 
- Visual acuity, near (Times Roman card @ 40 cm) [N5]:
  - Uncorrected: Right N?, Left N?
  - Corrected: Right N?, Left N?
 
Colour vision (Ishihara plates): ? errors.

*abnormalities*
Visual fields (confrontation): (-) right, (-) left.

Pupillary reflexes (light/accommodation): (-) right, (-) left.

Ophthalmoscopy: **abnormalities**

Right eye: 
(-) cataract
(-) retinopathy
(-) abnormal retinal vessels
(-) papilloedema
(-) other ->

Left eye: 
(-) cataract
(-) retinopathy
(-) abnormal retinal vessels
(-) papilloedema
(-) other ->

Investigation Results:

A: Assessment

Clinical Summary:

Diagnosis / DDx:

P: Plan

Investigations:

Treatment:

Referrals:

Patient Education / Home Care Advice:

Review:

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