Patient Case History Flashcards
The problem-oriented medical record system consists of?
Defined database
Complete problem list
Initial treatment plans
Progress notes
In defined database, procedures include:
Patient history
Preliminary examination
Ocular examination
Refractive examination
Binocular vision examination
Complete problem list includes:
List of px’s problem constantly changed
Systemic problem that has a ocular or visual effects/changes
List of problem not only the ones that can be solved by a student or practitioner
It provides information concerning diagnostic workup and management
Initial treatment plans
SOAP stands for
Symptomatic
Objective
Assessment
Plan
Provides permanent list at subsequent visits
Problem list
Provides forms available for use in CL fitting, vision therapy, LV px care
Progress visit
Determine the date or how often CL and glasses is prescribed
Ocular history
Present state of his or her health and nature of any current or recent illness
Health history
Questions concerning family ocular and health history directed mainly toward sight-threatening conditions
Family ocular and health hx
Blurred vision that occurs in bright daylight might be due to
Nuclear or subcapsular cataract
Blurred vision involving transient or obscuring vision in an older adult could be sign of
Temporal arteritis
Blurred vision involving transient loss of vision could be due to
Migraine syndrome or multiple sclerosis
High exophoria at near
Convergence insufficiency
High exophoria at distance
Divergence excess
Esophoric at both distance and near
Divergence insufficiency
A difference in the size and shapes of the retinal images for the two eyes
Aniseikonia
A type of strabismus wherein there is an adaptation to preexisting refractive or binocular vision problem
Functional strab
A type of strab that occur early in life that causes symptoms of eyestrain
Paralytic strab
Consists of prodromal visual aura, followed by a unilateral, throbbing HA accompanied by a feeling of nausea
Migraine HA
Severe, occurring early in the morning, usually being present in awakening and disappearing at some time during the day
Hypertension HA
Also known as histamine cephalgia
Cluster HA
Severe, boring, unilateral headache occurring in the temporal region
Cluster HA
Also known as tic douloureux
Trigeminal Neuralgia
An extremely sharp piercing, knife like pain, of sudden onset in the facial region
Trigeminal Neuralgia
An inflammatory process affecting the lid margins
Blepharitis
Atopic in form causes symptoms like tearing, redness in the eye along with edema of bulbar conjunctiva
Allergic conjunctivitis
Form of allergic conjunctivitis occurring in the spring and summer months
Vernal conjunctivitis
Causes irritation and redness, mucopurulent discharge and complains eyes sticking
Bacterial conjunctivitis
Triad of light sensitivity
Pain, photophobia, lacrimation
Caused by corneal ulcers, acute iritis, and acute glaucoma. Indication of internal condition is present of ciliary injection
Deep-seated ocular pain
Highly contagious, behind as an acute follicular conjunctivitis. Photophobia may be marked as symptom
Epidemic keratoconjunctivitis
Other term for epidemic keratoconjunctivitis
Adenoviral Conjunctivitis
AC/A
Accommodative Convergence/ Accommodation
RPE
Retinal Pigment Epithelium
AC
Anterior Chamber
O.D.
Doctor of Optometry
XT
Exotropia
KCS
Keratoconjunctivitis sicca
NPDR
Non-Proliferative Diabetic Retinopathy
PDR
Proliferative Diabetic Retinopathy
OU
Oculus Uterque