Individual Health Care Assessment
Individual Health Care Assessment
Individual Health Care Assessment
Name: EKP
Age: 66
Sex: Male
Address: Calle Humildad, Lunzuran, Zamboanga City
Civil Status: Married
Occupation: Private Employee
Religion: Roman Catholic
Nationality (Citizenship): Filipino
Ethnicity: Zamboangueno
Source of History/Referral: N/A
Chief Complaint:
Main S/sx: Stuffiness in the Eye
FAMILY HISTORY
Father is diagnosed with Asthma and Hypertension. Mother is diagnosed with
Hypertension and Gallbladder Cancer. Cause of death – old age.
REVIEW OF SYSTEMS
VS
1. HR – 88 bpm
2. BP – 123/78
3. Temp – 36.7 C
4. O2 Sat - 98
5. RR - 17
6. Pain Scale (usually sa una if pain ang Chief Complaint) - 3
General Appearance:
Received patient awake, conscious, and coherent, no recent weight change,
REVIEW
Head – no asymmetry, twitching, drooping, masses, lesions, swelling, dysfunction in the
cranial nerves C7 (facial), C5 (Trigeminal Nerve), no pain in sinuses
Eyes – Eyes are equally round, reactive to light and accommodation, conjunctiva is
reddish but no swelling. No abnormalities in Cranial Nerve 3 (Occulomotor), CIV and CVI
(Trochlear and Abducens)
Ears – no lesions, swelling, drainage, tenderness, masses. No abnormalities in the CVIII
(Vestibulocochlear nerve)
Nose – no abnormalities in respiration, nor any pain, discomfort, drainage, bleeding,
swelling, and abnormality in CI (Olfactory Nerve)
Mouth – No abnormalities in color, texture, CXII (Hypoglossal Nerve), CVII
(Glossopharyngeal Nerve), and CX (Vagus Nerve) tongue is pinkish with no lesions or
swelling
Neck – lesions, lumps, swelling, abnormalities in C11 (Accessory Nerves), no swelling or
flat neck veins, lymph nodes are nonpalpable, carotid artery are not bulging
Chest (Respi and Cardio) – no lesions and redness in the chest area, respiratory rate is
within normal limits, no abnormalities in the 5 areas of auscultation, no abnormal lung
sounds (bronchovesicular)
o Aortic Valve – 2nd ICS Right
Palpate jugular notch then down to sternal angle then go right at 2nd ICS
sound level (S2>S1)
o Pulmonary Valve – 2nd ICS Right
Same level with aortic valve but to the left (S2>S1)
o Erb’s Point – below pulmonary valve - 3rd ICS Right (S1=S2) – no valves
o Tricuspid Valve – base of heart at 4th ICS Right – (S1>S2)
o Mitral Valve – apical pulse near apex - Left Midclavicular Line at level of 5th ICS in
adult or 4th ICS in child
S1>S2 (Check 1 min)
Check HR – Normal: 60-100
Abdomen – no abnormalities in defecation, increased urination in night (nocturia), no
discomfort in the abdomen, no distention, swelling, color, lesions. Bowel sounds are at
25 per minute. No abnormalities in abdominal blood vessels.
GUT – no erythema, foul odors, discharge, lesions, warts
Upper extremities – no redness, swelling, lesions, bumps, radial pulse can be palpated
(at 88 bpm), capillary refill is at <2 sec, no abnormalities in range of motion
Lower Extremities – no abnormalities in color, swelling, soles of feet, toenails, capillary
refill is at <2 sec, reflex and range of motion are within normal range.
DIAGNOSTICS
1. Lab Tests
2. Diagnostic Tests
3. Px Diagnosis
a. Refer to ICD – 10 or any medical references to know how to diagnosis and patient
then justify why ganun ang diagnosis
4. PATHOPHYSIOLOGY OF OPEN GLAUCOMA
TREATMENT
1. Pharmacological – usually drugs
a. Can include indication, mechanism of action, side and adverse effects, dosage,
route, time
2. Surgical
a. What type of surgery, purpose, process
3. Supportive/Palliative
a. In the form of symptomatic treatment (i.e. Pain)
RF
Age (>40 y.o. for South Asian)
Perfusion pressure – older age means less blood flow to the eyes which in turn reduces
drainage of aqueous humor raising the pressure due to build-up
Caffeine consumption – stimulant – raising blood pressure
Possible – Race, Family History, Nerve fiber layer thickness, myopia
DIAGNOSTICS – established when glaucomatous optic disk or field changes are associated with
raised intraocular pressures, a normal-appearing open anterior chamber angle. Usually, they
have normal IOP so repeated tonometry is needed.
1. History
a. Visual Symptoms – N/A
b. Past medical history – asthma (C/I to beta blockers), systemic hypertension
2. Examination
a. Visual Acuity – normal except in advanced glaucoma
b. Pupils – Exclude a relative afferent pupillary defect (RAPD). If initially absent but
develops later, this constitutes an indicator of substantial progression.
c. Color vision assessment – may suggest optic neuropathy - Ishihara chart
d. Tonometry – measures IOP – normal 11-21 mmHg – my patient: 33 on right eye,
27 on left eye
e. Optic disc examination for glaucomatous changes – perform with pupils dilated
where red-free light can detect retinal nerve fiber layer defects
i. Neuroretinal rim – asymmetry of 0.2 or more between the eyes is at risk
ii. Optic disc size – decides if cup/disc ratio is normal. If large discs – mire
likely to sustain damage due to mechanical weakness
f. Stereo disc photography – optic disc imaging
g. Pachymetry – measures corneal thickness – influences accuracy of tonometry
h. Gonioscopy – measures the configuration of the angle whether it is wide, narrow,
or closed which can influence the outflow of the aqueous
i. Ultrasound biomicroscopy – imaging the anterior segment of the eye
3. Visual field defects – depends on progression of disease, involves mainly the central 30
degree of field.
DIFFERENTIALS
1. OCULAR HYPERTENSION (elevated IOP but no definite signs of glaucomatous optic
neuropathy) - Tonometry
2. NORMAL TENSION GLAUCOMA (all the features of POAG but IOP always measures
within normal limits) – Tonometry
3. Primary angle closure glaucoma (narrow drainage angle and eye pain) – Gonioscopy
4. PIGMENT DISPERSION GLAUCOMA (Krukenberg spindle, Iris transillumination, heavily
pigmented angle in all 360 degrees) – Slit Lamp Examination
5. PSEUDOEXFOLIATION GLAUCOMA (pseudoexfoliative material on pupil margin and lens)
– slit lamp visualization
6. STEROID-INDUCED GLAUCOMA (history of topical or systemic steroid range) –
medication history/cortisol blood test
7. POSNER-SCHLOSSMAN SYNDROME (mild inflammation, unilateral) – tonometry,
gonioscopy
8. Physiologic cupping (normal large optic disc with large cup: disc ratio; symmetric) –
asymmetric in POAG – stereo disc photography
9. Myopia (optic discs difficult to assess, associated with visual field defect not generally
progressive) – progressive in glaucoma – refraction test, visual acuity (SNELLEN), slit
lamp exam.
Treatment – no polypharmacy
Use – reduction of elevated intraocular pressure in patients with open-angle glaucoma and
ocular hypertension
1. Facilitation of Aqeuous Outflow
a. Prostaglandin analogs (bimatoprost, latonoprost) – once daily at night first line
agents. S/E – Conjunctival hyperemia; darkening of iris, eyelids, increase in
thickness of eyelids, local irritation, itching, dryness
i. Increase outflow of aqueous fluid through uveoscleral route.
b. Parasympathomimetic – Pilocarpine (Myotics – Cholinergic) – increase aqueous
outflow by action of the trabecular meshwork through contraction of the ciliary
muscle.
2. Suppression of Aqueous Production
a. Beta-blockers (C/I for Asthmatic – Sympatholytic – bronchoconstriction) –
betaxolol, carteolol, timolol. S/E – 1
i. Reduce production of aqueous humor
b. Apraclonidine – alpha 2 adrenergic agonist – sympatholytic – decreases aqueous
humor formation without effect on outflow. It prevents the rise of IOP – 3x daily
i. activate receptors in ciliary body, inhibiting aqueous secretion and
increasing uveoscleral aqueous outflow.
c. Brimonidine – 0.2% twice daily – alpha adrenergic agonist – inhibits aqueous
production and secondarily increases aqueous outflow. First-line or adjunctive
agent. S/E – fatigue, somnolence, drowsiness, local allergic reaction, dry eyes,
stinging
d. Dorzolamide Hydrochloride 2% and Timolol- carbonic anhydrase inhibitor as
adjunctive. Combined with timolol.
i. Decrease production of AH by inhibiting enzyme carbonic anhydrase.
e. Netarsudil (Rhopressa) – RHO Kinase Inhibitors – 0.02% 1 drop every morning-
S/E – conjunctival hyperemia, corneal verticillate, instillation site pain,
conjunctival hemorrhage, bliurred vision, increased lacrimation, reduced visual
acuity.
i. Inhibits the norepinephrine transporter. Decreases resistance in the
trabecular meshwork outflow pathway, and increases outflow of aqueous
humor.
f. Mirtogenol – countering retinopathy by improving ocular blood flow, in a study
conducted by Steigerwalt, Jr. et. al. (2008), 19 out of the 20 patients had
decreased IOP after three months of intake with no side effects. However, it is
still not considered as a viable treatment as it still has no approved therapeutic
claims.
SURGERY – only in angle closure glaucoma and other complicated diagnosis
1. Peripheral Iridotomy, Iridectomy, Iridoplasty –
a. Iridotomy – hole in iris – prophylaxis before closure attacks occur
b. Iridectomy – removal of iris
c. Iridoplasty – mechanically pulling open the anterior chamber angle
2. Laser Trabeculoplasty – reduces pressure by laser burning the trabecular meshwork to
facilitate aqueous outflow.
3. Trabeculectomy – bypasses normal drainage channels, allowing direct access from the
anterior chamber to the subconjunctival and orbital tissues.