Patient History Flashcards
take a complete, concise and orderly patient history (11 cards)
What is the purpose of obtaining a hx
to document all necessary info about a patient so you would know what diagnosis to suspect and what preliminary testing you should perform to rule in or out these diagnosis, and enough info so as not to injure the patient with treatment
Name three good qualities of a good Hx
Complete, Concise, Orderly
How would you obtain the Hx of a patient who arrives at the office with their daughter, who is hard of hearing, elderly, and who you suspect may not have good mental facilities?
Tell daughter that you will be asking her father some questions and if she wishes to add any info she should feel free to interrupt . sit closely to patient speak louder in a lower tone, and direct all your questions to the patient
when do you obtain a Hx in a small child’s exam
after stereo testing, va testing and motility balance
If a patient is on glaucoma medication what four things need to be recorded other than the medication name?
which eye used, how many times per day, percentage strength , time last used
if a patient reports past hx of head trauma from MVA what ophthalmic problems would we suspect and what questions would we ask to confirm this? also what question would we ask about the accident?
suspect fusional convergence/divergence insufficiency and ask if they have any problems when they read such as skipping lines, re-reading same line over, reading something and saying to self what did i just read, drowsiness when reading, getting closer and closer to reading , blurred vision after reading awhile
name 5 things u would ask if a pt complains about diplopia
onset of diplopia , constant or intermittent, vertical or horizontal or combination, diplopia at near or distance or both, binocular or still there when covering one eye
name 2 things that clearly differentiate prebyopia from fusional problems or phoria
A. Presbyopia- reading gets more clear the further away you hold it and with FCI/FDI reading has to be brought closer to maintain clarity
B. with prebyopia reading near is always blurry and with FCI/FDI reading gets blurry after awhile
what four things should you ask on a return exam
change in symptoms?still present?worse, better? any new allergies? any new medications? additional symptoms? change in health?
how would you record a patients statement that their vision was poor in one area and their general physician told them they had a tear in their cornea
patient states vision poor in (whatever area it was) , saw Dr. (whoever) and patient states “Dr. whoever I have a tear in my cornea”. ( put their statement in quotes)
reason for obtaining a Hx:
Medicare/Medical Insurance billing
Investigate patients complaints
uncover any undiagnosed pathology
determine if what testing to perform to rule out or in possible diagnosis
