NBEO-BCTM Patient Case Template for PPMs
Instructions
1) The designation of “xxxxx” represents a text field in which you may insert applicable data;
unused fields may be left as they are.
2) Some text fields are pre-populated with suggested, normal responses; you may replace
these as needed.
3) Additional ocular testing results may be added as needed (e.g., ophthalmometry,
gonioscopy).
4) A template of specific laboratory tests is included for your use; results may be filled in or
left as they are, depending upon which lab tests were ordered and performed.
5) Any additional lab test results may be added to the given roster of lab tests under the
heading provided (e.g., ESR, CRP, Ab titers); reference ranges must be included.
6) Any additional non-ocular testing results may be added under the heading provided (e.g.,
ultrasonography, x-rays, CTs, MRIs); interpretational information must be included.
7)
Ocular photos (e.g., fundus, lid, cornea) and any other relevant ocular test results images (e.g., VFs,
OCTs) may be included under the heading provided.
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
Chloride
CO2
Calcium
x.x meq/L
xxx meq/L
xx meq/L
x.x mg/dL
3.7 - 5.3
101 - 111
21 - 31
8.5 - 10.2
Cholesterol
Triglyceride
HDL
LDL
xxx mg/dL
xxx mg/dL
xx mg/dL
xxx mg/dL
< 199
30 - 149
> 40
< 130
HgbA1c
x.x%
4.0 - 6.0
RBC
Hgb
Hct
MCV
MCH
MCHC
RDW-CV
x.xx M/L
xx.x g/dL
xx%
xx fL
xx pg
xx g/dL
xx.x%
4.5 - 5.9 (male)
13.5 - 17.5 (male)
42 - 54 (male)
80 - 103
26 - 34
30 - 37
11.5 - 14.5
WBC
Neutrophil %
Lymphocyte %
Monocyte %
Eosinophil %
Basophil %
Platelet
MPV
x.x K/L
xx%
xx%
x.x%
x.x%
x.x%
xxx K/L
xx.x fL
3.9 - 11.0
49 - 78
20 - 45
3.0 - 9.5
0.0 - 4.0
0.0 - 3.0
130 - 400
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
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
Treatment / Management
Indicates the most appropriate treatment or management
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
B:
C:
D:
Modified 9.10.13 JET