Case History Flashcards
What constitutes the external evaluation?
Palpebral apterture
PD
What are the entrance tests?
Pupils EOM Confrontation fields/Amsler grid Cover Test with prism bar Color? Amplitude of accommodation NPC Stereo
What does a comprehensive history identify?
Diseases or conditions that may potentially have ocular manifestations
Medications that may have ocular side effects or may interact with drugs you plan on prescribing
What is a follow-up case history?
1-3 questions to explore the reason for the visit
*Ask about changes in symptoms and use of treatment
What is a problem focused case history?
1-3 questions to explore the reason for the visit
Generally for a specific purpose - ex. driver’s license
What is the SOAP format?
Subjective - the chief complains (symptoms)
Objective - exam observations and findings (signs)
Assessment - diagnosis
Plan - treatment and patient instructions
What are some possible tentative diagnoses for halos?
Corneal swelling Dirty contacts Cataracts Dry eyes Increased IOP
What are some tentative diagnoses for shadows?
Astigmatism
Cataracts
What are some tentative diagnoses for photopsia?
Flashes - retinal etiology
Longer - migraine
- transient ischemic attack
What are some tentative diagnoses for diplopia?
Binocular: Vergence or neurologic problem
Monocoular: Optic or retinal problem
What is accommodative dysfunction?
Spasm of near focus in patients under 35 y/o
Early presbyopia in patients 35-42
Words at distance blur after 10-20 minutes of near work; feel strained after near work
What symptoms may present themselves in binocular dysfunction/vergence dysfunction?
Diplopia at night Diplopia when reading Discomfort around eyes Words run together or move when reading Skipping lines or losing place when reading
What is asthenopia?
Eye strain
What are some things that can cause dry eye?
Contact lens wear
Allergies
Systemic disease
Systemic/topic medication
With what is photophobia usually related?
Inflammation/infection/trauma
