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
DS
Diopter Sphere
APD
Afferent Pupillary Defect
PH
Pinhole
TBUT
Tear Break-Up Time
LASIK
Laser Assisted In-Situ Keratomileusis
MPD
Monocular Pupillary Distance
IPD
Interpupillary Distance
HVID
Horizontal Visible Iris Diameter
VVID
Vertical Visible Iris Diameter
LP
Light Perception
LProj
Light Projection
GPC
Giant Papillary Conjunctivitis
PSC
Posterior Subcapsular Cataract
AV
Arteriovenous
BCVA
Best corrected visual acuity
HM
Hand motion
IOP
Intraocular pressure
OD
Oculus dexter
OS
Oculus sinister
External eye symptoms
Itching and burning
Pain or FB Sensation
Sensitivity to light
Excessive tearing
A feeling of dryness
Extreme sensitivity to light and excessive tearing in the first few months or years of life
Congenital glaucoma
Result of stimulation of the ophthalmic division of the trigeminal nerve
Excessive tearing
Outward turning of the eyelid margin
Ectropion
Inward turning of the eyelid margin
Entropion
Also known as keratoconjunctivitis sicca
Aqueous deficiency
An absolute or partial deficiency in aqueous tear production
Aqueous deficiency
Tear film layers:
Oil (lipid)
Aqueous
Mucin
Chief complaint may be due to to the presence of vitreous floaters
Seeing spots
Most commonly seen when looking at the sky or at the unconstructed background
Vitreous floaters
A form of chronic anterior uveitis affecting the pars plana
Pars planitis
Complaints of seeing red spots may be caused by hemorrhages within the retina
Retinal hemorrhages
Visual aura followed by a sick HA
Migraine scotoma
Classic cause is keratoconus
Monocular diplopia
Who developed the problem oriented optometric records?
Laurence Weed
Management for convergence insuff
Plus lenses
Management for divergence excess
Base out prism
A vicelike pain in the forehead, a pain located in the occipital area accompanied by muscular stiffness
Tension HA
Distortion of object size and shape is called
Metamorphopsia
Blurred vision that accompanies a unilateral change in refraction
Nuclear sclerosis
In an older patient, blurred vision that is not due to a change in refraction is most likely due to
Lens opacities or ARMD
Blurred vision occurring in reduced illumination may be due to
Night myopia or receptor degeneration
Possible cause of unilateral acuity loss
Functional amblyopia
If a patient has latent hyperopia what procedure should be done?
Cycloplegic refraction
What are the binocular vision syndromes?
Convergence and divergence insuff, convergence and divergence excess
Explain LOANER lenses
Prescribing a low powered spheres, cylinders, or low-power prisms
Management for migraine HA
going to bed
Ergotamine tartrate
drinking a cup of black coffee
Temporal arteritis often leads to
Ischemic optic neuropathy
Treatment for blepharitis
Washing hair or scalp using a Selsun shampoo
Removing the scales using a cotton applicator
Most prominent symptom of allergic conjunctivitis
Intense itching
Main symptom of vernal conjunctivitis
Extreme itching
Treatment for allergic conjunctivitis
Cold compress
Antihistamines
Most prominent symptom of bacterial conjunctivitis
Irritation and redness
Appearance of spots, strings, cobwebs or rings is called
Muscae volitantes
Minification of the retinal image
Accommodative micropsia
Presence of rainbow halos around lights is a classic symptom of
Angle closure glaucoma
A condition in which one or both inner canthal areas are partly covered by a fold of skin
Epicanthus
One pupil is larger than the other
Essential anisocoria
4 color anomalies
Protanopia
Deuteranopia
Protanomaly
Deuteranomaly
Strabismus that occurs during adult life is a result of
Paralysis of an ocular muscle or nerve
Functional strab is said to be
Concomitant
Paralytic strab is usually
Incomitant
Management for aqueous deficiency
Artificial tears
Clinical signs of keratoconus
Thinning and protrusion of cornea
Blurred vision after prolonged near work for a patient not of presby age
Uncorrected hyperopia, uncorrected astig, poor facility of accomm
Blurred vision in reduced illumination as in night driving
Retinitis pigmentosa
A term used to describe any complaint involving a feeling of fatigue, discomfort or pain
Eyestrain
A term used as a synonym for eyestrain
Asthenopia
According to Donders, asthenopia could be due to?
Excessive use of accommodation
