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Lab Report (Case History (General Health (HA's (food related), no…
Lab Report
Case History
Chief Complaint
routine check
feels dist vision decreased slightly
Family history
no cataracts
no AMD
no glaucoma
General Health
HA's (food related)
no flashes/floaters
never eye surgery/infections
no specs as child
taking Polycytemia meds
no diab/ HBP/ Chol
German measles as child
non smoker
Optical
no dist specs before
lost Rx reading specs
wearing specs found on bus
Binocular vision
cover uncover test
motility test
mallett unit
Additional tests
tonometry
Amsler grid
would have done fields(but ran out of time)
Refraction
Objective
static retinoscopy
no accommodation test as Px over 70
Subjective
best vision sphere
lens dobbing
Jackson cross-cylinder
final duochrome check
Ophthalmoscopy
Direct
ophthalmoscope
Indirect
volk lens & slit lamp
fundus photography
Occupation/Hobbies
bus driver
computer 1hr a day
Management
referral letter for full dilated EE
new Varifocal specs