Ophthalmology Clinical Case Proforma

For Ward Presentation — Department of Ophthalmology
 |  Date:

1. Identification & Presenter Details

Patient Name
Age / Sex
IPD / Bed No.
Occupation
Address
Date of Admission
Presenting Student & Roll No.
History given by

2. Chief Complaints

Tick all that apply. Specify eye involved (Right/Left/Both) for each.
✓Chief ComplaintSideSiteDuration (since)
Diminished vision
Redness of eye
Watering of eye
Eye pain
Itching in eyes
Foreign body sensation
Double vision (diplopia)
Squint
Trauma to eye
Difficulty seeing at night / halos
Other:

3. History of Present Illness

Mode of Onset

Character of Pain / Key Symptom — SOCRATES

To be filled whenever eye pain is a chief complaint.
S — Site
O — Onset
C — Character
R — Radiation
A — Associated symptoms
T — Timing
E — Exacerbating / relieving factors
S — Severity (0–10)
Associated symptoms

4. Past, Personal, Family & Treatment History

Past History

Family History

Personal History

Treatment / Drug History

5. General Physical Examination

Build
Nutrition
Consciousness
SignAbsentPresentDetails (site / grade)
Pallor
Icterus
Cyanosis
Clubbing
Lymphadenopathy
Edema

Vitals

PR (/min)
BP (mmHg)
RR (/min)
Temp
SpO2 (%)
RBS
GCS

6. Ocular Examination

A. Visual Acuity

ParameterRight Eye (RE)Left Eye (LE)
Unaided visual acuity (Snellen's)
Best corrected visual acuity
Near vision
Intraocular pressure (mmHg)

B. Extraocular Movements & Pupils

Extraocular movements
Pupillary reaction
Squint

C. Anterior Segment Examination (Slit Lamp)

StructureRight EyeLeft Eye
Lids & adnexa
Conjunctiva
Cornea
Anterior chamber
Iris
Lens

D. Posterior Segment Examination (Fundus)

StructureRight EyeLeft Eye
Optic disc
Retinal vessels
Macula
Periphery

E. Additional Tests

7. Systemic Examination

SystemNormalAbnormalDetails
Cardiovascular System
Respiratory System
Central Nervous System

8. Investigations

✓InvestigationFindings
Fundus photography
Optical coherence tomography (OCT)
Perimetry / visual field
B-scan ultrasonography
Fluorescein angiography
Blood sugar (F/PP) / HbA1c
Blood pressure recording
Other:

9. Diagnosis

Provisional Diagnosis
Differential Diagnosis

10. Treatment Plan

11. Summary

Auto-generated from ticks & entries above, in the fixed order of the sections — edit freely before presenting.
Presenting Student's Signature
Countersigned by Faculty / Resident
Ophthalmology Clinical Case Proforma — for teaching purpose · not a legal medical record