Lecture 2 case history Flashcards
What is a patients consitituion?
how they generally feels, fever, well, achy
T/F you want to review the 10 body systems with the patient
T
To record follow up case history and problem focused history use SOAP-what does it stand for
subjective-chief complaint
objective-exam observations and findings
assesment, diagnosis
plan, treatment
tentaive diagnosis with rings around lights/streaks from light
corneal swelling, dirty contacts, cataracts, dry eyes,
If a shadow occurs around letters most likely (myopia/astigmatism/cataracts/hyperopia)
cataracts, astigmatism
T/Fwhen a pt sees flashes of lights its called photopsia
T
When a pt sees floaters , you want to as them what?
recent onset or longstanding
changes in shape/size/frequency
-associated with flashes
T/f if pt has longstanding unchaned floaters it is less concerning
T
T/F new onset, changing or assiated with flashes may make retinal exam a priority
T
If diploplia is monocular what are the possible problems?
(retinal/optical/vergence/neurological )-pick two
optical or retinal
If diploplia is binocular what are the possible problems?
(retinal/optical/vergence/neurological )-pick two
vergence, neurologic
When words blur after 10+20 minutes of new work and are blurry at distance and feel strained after near work describes (accommodative dysfunction/myopia/hyperopia)
accommodative dysfunction
- Double vision at night
- Double vision when reading
- Discomfort around eyes
- Word run together or move when reading
- Skipping lines or losing place when reading
binocular dysfucniton/vergence dysfunciton
Vague eye discomfort arising from use of the eyes may consist of eyestrain, headach, and or browache desribes :
(astigmatism/asthenopia/aspirate)
asthenopia
Abnormal sensitivity to light
Usually associated with infection /trauma
descibes (ashthenopia/photophobia/ocular discomfort)
photophobia
-_____can have a multitude of causes
Related/unrelated causes
Take all complaints of ____ very seriously
Explore possible reasons for the ____ in the ____history
(fill in blank with the same word for all)
headache
Refer/consult
Visual Field exam
Neuro- exam
–ALL are test strategy for ?
headaches
Testing Strategy for (photophobia/accomodation)
Dry eye evaluation
Careful evaluation for uveitis
photophobia
Testing Strategy for (accommodative dysfunciton/myopia/hyperiopia)
Visual Efficiency Evaluation work up for patient <35y
Near work/presbyopia work up for patient over 35y
accommodative dysfunction
T/F case history only happens at the very beginning of an exam
F Case history continues throughout the exam
- Computer Users
- Contact Lens Wearers
- “Red Eye”
- Geriatric
- Pediatric
- Trauma
- Headaches
- -all of these describe?
special case histories
- Fatigue or strain
- Brow aches or head aches
- Blur at near
- Blur at distance at the end of the day
- Dry eye complaints: gritty, sandy
- -all describe symptoms of (trauma/red eye/computer users)
computer users
Is there a source of intrusive light behind you?
How is the ambient lighting in your office?
How often do you take breaks?
–all these questions would be asked to a (trauma pt./computer user/red eye pt)
computer user
-How long have you worn them today?
-Do you nap in your lenses?
-How many nights a week do you sleep in your lenses?
-Have you ever been treated for a red/ eye/ infection/ abrasion?
-How do you clean and disinfect your lenses? -Which care system?
-Do you currently have any problems with your lenses/wear?
ARe some questions to ask ___ wearers
CL
Besides FODLARS what other question would you ask a pt. with red eye?
allergies/contraindictions–important to know if you are plannign to treat with medications
T/F a parent or care giver doen’t need to be present at all times in pediatric exams
F Parent or care giver must be present at all times
T/F Written consent must be obtained for dilation in a pediatric exam
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- If child was full term delivery
- About unusual habits- reading too close, head tilts, squints
- How is the child performing in school
- Ask if child rubs eyes, has redness or crusting
these are all questions to ask in pediatric exams
T/F in geriatric exams a family member must alwasy be present
F A family member may be present and give history
T/F you do not need to confirm with the patient for privacy in an exam if family member is present already (during geriatric exam)
F Be sure to check with the patient that that person may be present in the exam room!
Ask if the patient prefers to be seen privately
T/F Any further communications may occur only if the person is specifically listed in the patient’s HIPPA file. (in geriatric exam)
T
T/F you do not need to document the name and relationship of the historian in the chart
F YOU DO!
- Dizziness or stroke?
- Has your vision affected the quality of your life?
- Any recent changes in your vision?
- -these are additional questions to ask in a (pediatric/geriatric) exam
geriatric
Only about __% of headaches are eye related
A)50
B)30
C)20
D)40
20
T/F you want the pt to describe the type of headache they have if any for example bilateral, achy, dull, worse at the end of the day, or improved by a nap
T
- Tension
- sinus
- migraine
- cluster
- mass effect
- -all describe what?
types of headaches
Stress realated band like describe (tension/sinus) headaches
tension
history of allergies, behind eyes or right through eyes, gravity increases frontal pain :describe (tension/sinus) headaches
sinus
- Usually male, episodic, chronic knife-like pain
- Pacing
- Unilateral pain, associated with unilateral stuffy/running nose
–all describe what type of headache
(migraine/cluster/mass effect)
cluster headache
- Pulsating, throbbing
- Can last several days
- Dark room, sleep
- May be associated with aura
- Triggers: food, cheese, wine, chocolate, MSG, aspartame
- Photophobia and phonophobia
- More common in females
–all describe what type of headache
(migraine/cluster/mass effect)
migraine
Worst headache of my life =aneurysm until proven otherwise!
–all describe what type of headache
migraine/cluster/mass effect
mass effect
Brain tumor, meningitis, aneurysm, increased intracranial pressure
Typically intermittent, deep and aching (non-throbbing)
Sub-acute and gets worse over days to weeks
Worse in the morning =red flag
Worse when lying down
Wakes patient from sleep= red flag
Associated with vomiting with/without nausea
–all describe what type of headache
(migraine/cluster/mass effect)
mass effect
T/F hypoglycemia, hypertension, can give headaches
T
