ASSESSMENT FORM

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

HISTORY OF PRESENT ILLNESS:

 2 months prior to consultation, patient noticed occasional blind spots in side vision
(peripheral vision) aggravated by lack of sleep, prolonged gadget use
 3 days prior to consultation, patient experienced dizziness, occasional blind spots,

PAST MEDICAL HISTORY:

 No history of previous hospitalizations, (-) DM, (+) HTN, (+) Asthma
o Drugs as maintenance – Amlodipine (CCB), Telmisartan (ARBs), Atorvastatin
(Statin)

FAMILY HISTORY
 Father is diagnosed with Asthma and Hypertension. Mother is diagnosed with
Hypertension and Gallbladder Cancer. Cause of death – old age.

PERSONAL AND SOCIAL HISTORY

 Non-smoker and non-alcoholic drinker. Loves to eat vegetables (green leafy), likes to
consume fried food (fried fish, chicken, pork, and beef), but is exposed to a smoker.
 Activities of daily living is sedentary – does not involve self with running or walking with
the prescribed amount of hours per week.
 BMI – 33.12 - obese
 Developmental milestones: Integrity vs Despair – through the interview, he described
that he feels satisfied because he has raised wonderful children who have set successful
careers and that he does not wish to go back since what he experienced in his life may
not all be happy but the happy moments overcome moments of failure.
 Source of water: Level 2 piped water with a communal water point serving 7 households
within a 25 meter distance
 Food preparation: Uses stove for cooking,
o 4 rights: right source – only buys fresh vegetables and also grows their own
vegetable
o Right prep – washes their ingredients thoroughly before cooking
o Right cooking – thoroughly cooks their food (only 70 degrees and above)
o Right storage – never leaves food in room temp for more than 2 hours
 Toilet Facility: Sewage system – to treatment plant
 Sexual history/preferences: Only has 1 sexual partner (wife) in his entire life,
Heterosexual (straight)

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)

GLAUCOMA – leading cause of blindness

 Progressive optic neuropathy
 Visual field loss
 Thinning of retinal nerve fiber
  Normal: aqueous humor produced from plasma by ciliary epithelium uses active and
passive secretion. A high protein filtrate passes out of the fenestrated capillaries into the
stroma of the ciliary processes, from which active transport occurs across the dual-
layered ciliary epithelium. The osmotic gradient facilitates the passive flow of water into
the posterior chamber. This is mediated by the sympathetic nervous system
 Ciliary body to Aqueous humor to trabecular meshwork to canal of schlemm
 Anatomy: Trabecular meshwork is a sieve-like structure at the angle of the anterior
chamber through which 90% of aqueous humor leaves the eye. 10% passes across the
face of the ciliary body and is drained by the venous circulation in the ciliary body.

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

OPEN ANGLE GLAUCOMA – chronic progressive optic neuropathy in which there is a

characteristic acquired atrophy of the optic nerve and loss of retinal ganglion cells and their
axons. (Ophtalmology, Duker, Yanoff)
Screening:
 There is usually an absence of symptoms until relatively late in the disease – if they first
notice a field loss – it is a sign that substantial optic nerve damage has occurred.
Pathogenesis – Aqueous humor has complete physical access to trabecular meshwork, and the
elevation in IOP results from an increased resistance to aqueous outflow in the open angle.

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.

HEALTH TEACHING – GLAUCOMA

1. Take medication as prescribed, report to doctor or nurse for adverse reactions.
2. Use eyedrops as directed:
a. Bend head back, look up toward the eyebrows. Gently pull the lower lid down.
This will make a small pocket.
b. Drop the medicine into the pocket (do not touch eyelid). Close your eyes for 2
minutes. This gives your eye time to absorb the medicine. Try not to blink
c. While your eyes are closed, press your fingers gently against the area between
the inner corner of your eye and your nose. This will prevent the drops from
getting into your nose. This is important to do because if the drops get into your
nose, this can cause side effects.
d. If more than one kind is prescribed, wait at least 5 minutes before using the next
one.
3. If multiple doctors, make sure the other doctors know your condition and medication to
prevent adverse drug interactions.
4. Eat a healthy diet – include zinc, copper, selenium, vitamin C, E, A.
5. Limit caffeine – stimulants, may increase IOP