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36 Cards in this Set
- Front
- Back
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Chief Complaint
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State in patient’s own words
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History of Present Illness (HPI)
Deals with analysis of symptom (to be discussed) |
Deals with analysis of symptom
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Past Medical History (PMH)
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History of past health
Hospitalizations/surgeries both ophthalmic and general Illnesses/injuries Previous eye disorders Immunizations Medications (Rx, OTC, herbals)/Duration of use |
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Allergies to drugs (also taken internally or applied topically)
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Inhalants :dust pollen
Contactants cosmetics, wollens ect. Ingestants : food Injectants : tetanus antiserum |
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Family History
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Picks up on trends in the family
High risk groups If nothing, can state “Family history is negative". |
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Myopia
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Myopia -5
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Strabismus
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Strabismus
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Glaucoma
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Glaucoma
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Blindness
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Blindness
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Pro-banthine for Ulcer difficulty seeing near
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Atropine-like in Ciliary body
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“OLD CART”
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O Onset
L Location D Duration C Characteristics/course A Associated/Aggravating R Relieving factors T Treatments/Responses |
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Diagnostic testing
Medications Other treatments Referral Education Follow-up |
?
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Personal History
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Often called “
social history” Personal habits (diet, exercise, drug/alcohol use, occupation) Sexual activity |
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Occupational history
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Type of work (exposures)
Place and type of employment |
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Probe for CC
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c/o pain,
eye fatigue blurred near vision blurred distant vision |
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date of onset
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date of onset
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cause
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cause
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duration
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duration
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urgent symptoms
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pain
sudden LOV transient LOV Diplopia Ptosis Flashes of light |
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moderate (prompt attention)
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morning discharge/matting of lids
red eye swelling of eye haloes around lights blurred vision in elders persistent tearing one eye enlarging nodule on lid foreign body sensation sans pain |
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significant symptoms (to be seen ASAP
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gritty feeling
H/A adult blurred distant vision spots before eye pain behind eye eruption/blisters/pustules on skin |
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Is PT wearing contacts?
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Is PT wearing glasses?
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how old are glasses/CL?
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When was last exam?
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Record any previous therapy and the response
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Record any previous therapy and the response
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Nature of the presenting problem, including chief complaint
• Visual and ocular history • General health history, which may include a social history and review of systems • Medication usage, including prescription and nonprescription drugs; use of mineral, herbal, and vitamin supplements; documentation of medication allergies; and utilization of other complementary and alternative medicines • Family eye and medical histories • Vocational and avocational vision requirements • Identity of patient's other health care providers |
Nature of the presenting problem, including chief complaint
• Visual and ocular history • General health history, which may include a social history and review of systems • Medication usage, including prescription and nonprescription drugs; use of mineral, herbal, and vitamin supplements; documentation of medication allergies; and utilization of other complementary and alternative medicines • Family eye and medical histories • Vocational and avocational vision requirements • Identity of patient's other health care providers |
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when did it start, what’s it like, is there anything that makes it better or worse, are you taking any medications for relief, etc..
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when did it start, what’s it like, is there anything that makes it better or worse, are you taking any medications for relief, etc..
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Blurry vision: Is the vision always blurry? Does it worsen when reading or watching TV
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(people blink less when watching TV and develop dry eyes)
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Red, painful eyes: A common complaint. Be sure to ask about the nature of the pain
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(is this a scratchy pain, aching pain, or only pain with bright light). Is there discharge that might indicate an infection?
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Find out what eyedrops your patient is taking, and why. Are they using a regular eyedrop? How about vasoconstricting Visine? Did they bring their drops with them?
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If your patient can’t remember their medications, it often helps to ask about the bottlecap-color of their drops (ex. all dilating drops have red caps).
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Snellen letter chart (if Pt can’t read the E on the top line, see if they can count fingers at different distances.
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Failing this, try hand motion and light. Poor distance vision usually occurs from refractive error (your patient needs better glasses).
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Goldman Applanation Tonometer”
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attached to the slit-lamp microscope.
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Visual fields
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Confrontational fields patient cover one eye, and tell them to look straight at your nose.
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If, after covering an eye, the vision stays doubled, you know you’re dealing with monocular diplopia. Monocular diplopia
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isn’t a neurological problem, but likely from a refractive error such as astigmatism, cataract, or corneal surface wrinkling.
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Binocular diplopia indicates a misalignment between the eyes … and this is likely due to
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neuromuscular paralysis or muscle entrapment
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ptosis (drooping of the eye) or proptosis
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(extruding eyes or “bug-eyes”).
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if the anterior chamber is deep and well-formed, or shallow
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a setup for angle-occlusion glaucoma
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