NBEO-BCTM Patient Case Template for PPMs

Demographics

age-year-old race gender; occupation

Chief complaint

xxxxx

History of present illness

Character/signs/symptoms: xxxxx

Location: xxxxx

Severity: xxxxx

Nature of onset: xxxxx

Duration: xxxxx

Frequency: xxxxx

Exacerbations/remissions: xxxxx

Relationship to activity or function: xxxxx

Accompanying signs/symptoms: xxxxx

Secondary complaints/symptoms

xxxxx

Patient ocular history

xxxxx

Family ocular history

mother: xxxxx

father: xxxxx

Patient medical history

xxxxx

Medications used by patient

xxxxx

Patient allergy history

xxxxx; NKMA

Family medical history

mother: xxxxx

father: xxxxx

Review of systems

Constitutional/general health: excellent

Ear/nose/throat: denies

Cardiovascular: denies

Pulmonary: denies

Endocrine: denies

Dermatological: denies

Gastrointestinal: denies

Genitourinary: denies

Musculoskeletal: denies

Neurologic: denies

Psychiatric: denies

Immunologic: denies

Hematologic: denies

Mental status

Orientation: oriented to time, place, and person

Mood: appropriate

Affect: appropriate

Clinical findings

BVA: Distance Near

OD: 20/xx 20/xx

OS: 20/xx 20/xx

Pupils: PERRL, negative RAPD

EOMs: full, no restrictions

Confrontation fields: FTFC OD, OS

Slit lamp:

lids/lashes/adnexa: unremarkable OD, OS

conjunctiva: normal OD, OS

cornea: clear OD, OS

anterior chamber: deep and quiet OD, OS

iris: normal OD, OS

lens: clear OD, OS

vitreous: clear OD, OS

IOPs: xx mmHg OD, xx mmHg OS @ hr:min am/pm by applanation tonometry

Fundus OD:

C/D: xx H/xx V

macula: normal

posterior pole: normal

periphery: unremarkable

Fundus OS:

C/D: xx H/xx V

macula: normal

posterior pole: normal

periphery: unremarkable

Additional ocular tests:

Blood pressure: xxx/xx mmHg, right arm, sitting

Pulse: xx bpm, regular

Body mass index: xx.x

Reference ranges

<18.5 underweight

18.5 - 24.9 normal

25.0 - 29.9 overweight

>30.0 obese

Laboratory tests: Results Reference ranges

Glucose xxx mg/dL 65 - 115 (fasting)

Urea nitrogen xx mg/dL 5 - 24

Creatinine x.x mg/dL 0.7 - 1.4

Sodium xxx meq/L 136 - 146

Potassium x.x meq/L 3.7 - 5.3

Chloride xxx meq/L 101 - 111

CO2 xx meq/L 21 - 31

Calcium x.x mg/dL 8.5 - 10.2

Cholesterol xxx mg/dL 199

Triglyceride xxx mg/dL 30 - 149

HDL xx mg/dL > 40

LDL xxx mg/dL < 130

HgbA1c x.x% 4.0 - 6.0

RBC x.xx M/mL 4.5 - 5.9 (male)

Hgb xx.x g/dL 13.5 - 17.5 (male)

Hct xx% 42 - 54 (male)

MCV xx fL 80 - 103

MCH xx pg 26 - 34

MCHC xx g/dL 30 - 37

RDW-CV xx.x% 11.5 - 14.5

WBC x.x K/mL 3.9 - 11.0

Neutrophil % xx% 49 - 78

Lymphocyte % xx% 20 - 45

Monocyte % x.x% 3.0 - 9.5

Eosinophil % x.x% 0.0 - 4.0

Basophil % x.x% 0.0 - 3.0

Platelet xxx K/mL 130 - 400

MPV xx.x fL 7.4 - 12.0

Additional laboratory tests:

Additional non-ocular tests:

Ocular images:

Case diagnosis:

Treatment:

The PPM Patient Case Content text fields represent where the participant can insert the applicable diagnosis and treatment information)

ITEM TYPE / PPM Patient Case CONTENT
A: / Diagnosis
Indicates the most appropriate diagnosis
B: / Related to Diagnosis
Relates to data supporting or correlating with the diagnosis; or the correlation of possible additional data; or indicates additional data or the next test needed
C: / Treatment / Management
Indicates the most appropriate treatment or management
D: / Related to Treatment / Management
Relates to the treatment mechanism; describes additional data needed to treat effectively; indicates additional next test needed; describes patient education; relates to follow-up; or forecasts prognosis

Modified 9.10.13 JET