NBEO-BCTM Patient Case Template for Ppms

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/L 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/L 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/L 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