History and Documentation 4% Flashcards
What is chief complaint
Reason for visit: Brief 1-2 Sentence, pt own words. Main reason for enounter.
What is HPI?
History of present illness. Story of the CC.
Date of onset, Location(where is pain), Quality(sharp pain?), Duration(how long), Timing(when did it start), Context(what was pt doing), Severity(degree of pain), Modifying factors(what makes it better), Associated signs and symptoms.
*A sign is…
A Symptom is….
A sign is objective (can see)
A symptom is subjective (can’t see, what pt feels)
What is ROS?
Review of Systems. Inventory of Body’s Systems
*What is PFSH?
Past & present health conditions, family, social hx.
Is it important to document name of current physician treating major system conditions such as HTN, cardiac disorders, arthritis, DM (how long diagnosed, stable or unstable, last BC, last A1C)
Yes
What conditions should be documented under Family Hx?
Ocular: myopia, strabismus, glaucoma, blindness, cataracts.
General: DM, Heart disease, Cancer, HTN
Significant Herditary conditions: Migraines, Retinitis pigmentosa, Retinoblastoma, color blindness, Nystagmus, Sickle Cell Anemia, KCN, Marfan’s Syndrome, DM, Hereditary Macular Degen (Stargardt’s Disease)
Name medications with Ocular Side Effects.
Plaquenil (Hydroxychloroquine), Tamoxifen, Viagara, Amiodarone, Flomax.
What ocular side effect does Plaquenil(Hydroxychloroquine) have?
Retinal deposits, loss of central VA(VF Central 10 degrees), night vision
What ocular side effects does Tamoxifen have?
This med is used for Breast cancer (10 years to prevent reoccurence)
Decreased VA, Retinopathy, Optic neuritis, sub-epithelial K deposits.
What ocular side effects does Viagra (Sildenafil) have?
NAION, altered color VA, Blurred VA, light sensitivity.
What ocular side effect does the cardiac drug Amiodarone have?
K deposits, lenticular opacities, optic neuropathy.
What ocular side effect does Flomax(Tamsulosin) have?
Floppy Iris Syndrome
What does Ischemia mean?
Lack of blood flow
Name some general groups of drugs with ocular side effects.
Corticosteroids, Chemotherapy agents, Contraceptives, Antihistamines, Antidepressants, Abx, Anticoagulants, Salicylates(aspirin)
What ocular side effects does Corticosteroids have?
Increased IOP, *PSC cataracts(know which type of CAT steroids cause)
What ocular side effects does Chemotherapy agents have?
Conjunctivitis, Dry eye, ocular inflammation & edema
What ocular side effects does Antihistamines have?
Dry eyes, pupil dilation, blurred VA
What ocular side effects does Antidepressants have?
Blurry VA, pupil dilation
What ocular side effects does ABX have?
Keratopathy, conj inflammation, ptosis, optic neuritis, papilledema.
What ocular symptoms do Anticoagulants have?
Subconj heme, vitreoretinal heme, pre-surgical eval
What ocular symptoms does Salicylates (aspirin) have?
Diplopia
What are the types of allergies?
Drugs(ocular meds), Inhalants, Contactants, Ingestants, Injectants.
What is the Induction Period with allergies?
Name the typical allergic responses.
Itching, Skin rash, Difficulty breathing, Rapid/weak pulse, Nausea, vomiting
Blurred VA secondary to Refractive Error
Is at a particular distance and specific activity
Blurred VA secondary to Organic Disease
Usually all distances, activities
Vision loss may be better in dim illumination, VA usually poor, and is Sudden onset(usually optic nerve or macular origin)?
a. Loss of Central Vision
b. Distored Vision
Loss of Central vision
Macular disorders, High Myopes or thick glasses, Objects may appear minimized and fuzzy with curved edges…
a. Loss of Central Vision
b. Distorted Vision
b. Distorted Vision
*Night blindness can be symptom of…..
RP(Retinitis pigmentosa) or Vitamin A deficiency
__________visual loss can be one or both eyes, seconds to minutes, may be symptoms of Papilledema 2 degree to increase ICP, CAD, Carotid Insufficiency, swelling of the optic nerve.
Transient
*Inability to see to the left or right, disability with daily tasks or ambulation
Suspect neuro origin on opposite side of VF loss.
Ascending Veil
Dark shadow arising from inferior VF,
Frequently sign of superior RD.
What questions should be asked with diplopia?
Which eye or both?
Does it go away when you cover one eye or the other? (monocular or binocular)
Are the images vertical, horizontal, or oblique to one another?
Is it true double or an image and ghost image?
With glasses, without, or both?
Distance or near?
What questions should asked with Headaches?
Where is it?
Do you ever wake up wit it?
With or without glasses or both?
What tasks are you performing when you get them?
Any visual disturbance?
Nausea, vomiting?
(Know migraines and symptoms)
What questions should be asked with Visual Disturbance?
Any apparent cause?
Did you feel unusual before, during or after?
One eye or both?(brain)
Headache?
Duration?
Nausea, vomiting?
What questions should be asked with Trauma?
What did they hit?
Did they have glasses on?
Loss of consciousness? (L.O.C)
Did they seek other medical care or have imaging done (i.e. CT, MRI)?
Change in vision?
Flashes or floaters?
Work or auto related?
Questions to ask for children…
Eyes drifting or turning?
Head tilt or turn?
Do you think s/he sees well?
How is s/he doing in school?
Who is the pediatrician?
What are the 2 types of vision loss?
Blurred VA 2nd to Refraction
Blurred VA 2nd to organic disease
Which Vision loss occurs at a particular distance and with specific activity?
2nd to Refractive error
Which vision loss usually occurs at all distances and activities?
2nd to Organic Disease
