PRACTICAL OPHTHALMOLOGY PDF
Practical Ophthalmology: A Concise Manual for the Non- ophthalmologist . need for another ophthalmology book, and concluded that one should be written . PDF | a manual of practical ophthalmology for medical students. Practical Ophthalmology - A Manual for Beginning Residents ()(1).pdf - Free ebook download as PDF File .pdf), Text File .txt) or read book online for free.
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Ophthalmology PDF Books 1-Anatomy. 5-Practical Ophthamology,A Manual for Beginning Residents 6-Wong Ophthalmology Examinations Review. Practical Ophthalmologya Manual for Beginning Residents. Reviewed by J SCOTT Full Text. The Full Text of this article is available as a PDF (68K). This book is aimed at the trainee ophthalmologist starting his first post in ophthalmology who has a steep learning curve with much new information and new.
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Practical Ophthalmology: A Manual for Beginning Residents
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Read comfortably by adjusting the settings for zoom, font size and brightness. After downloading your Academy eBook s , follow these directions to access content: To access from nearly any computer with an Internet connection: T he fact remains tha t th e task of mas tering op hthalmo logy can appea r daunting to the begin - nin g resident. T he re are no good su bstitu tes for hard work com bined with effective time management. A disciplined approach to knowledge acqu isition , patient care, and ethic al practice will lead to a pr ofession al life wi th continually increasing reward s.
Glaucoma medical therapy : principles and management
Ethical Considerations Ethics are reflect ions of our mo ral values. Your eth ical standing is a reflection of your actions and atti tu des. Th e ethical practice of ophthalmology mu st at all times be borne in mind by th e physician-in -training. It safegua rds the health y found atio ns of th e do ctor -patient relationship.
T he p rin ciples invo lved, forma lized in the Code of Eth ics of the Ame rican Aca demy of Ophth alm ology, are designed to ens ure that the best inte rest of the patient is p aram oun t. These principles can be summarized as the fo llowi ng:. Inst ead, always refer to pa tients by their nam es, except in public situations w here pat ient confi dential ity must be mainta ined.
An ill, pro blem-ri dd en physic ian is less likely to empa thize genuinely wi th the minor ailme nt s of pa tients. Patients o r fam ily members might appear frighte ned, an gry, or hostile.
Learn to recognizc and to dea l effectiv ely w ith these emotions wi thou t ever beco ming defensive or hostil e vo ur self. C linical competence is accomplished by continued stu dy and by appropriate cons ultation.
Moral com- pe tence calls upon th e ph ysician to practice moral discernm ent unders tand and resolve the ethical impl ications of clinical enco unt ers , mora l agency act faith- fully and respectfull y on behalf of the pat ient , and caring in th e docto r-patient relationsh ip. Ne ver misrepresent yo ur status. Introdu ce yo urself by name and ident ify yo urself as a resident. Provid e complete and accurate information about treatment options.
Reflect this in yo ur ow n actions and attitu de by placing yo ur patien t's welfare ahead of your person al ambitio ns and desires. Education and Training T he ph ysician-i n-training must strive to achieve a balance between educa tion and tr ain- ing. Training conno tes learning to perform specific tasks, such as examinatio n steps and surgical procedures.
The meaning of educa tion is much bro ader, ent ailing the th ou ghtful int egration of new knowledge int o one's own person al experiences, insights, and actio ns. Residency training must be supp lemented by self-driven education. It can be argued th at the single most important factor th at determin es an excellent residency training outcome is th e individual's own input into the education and training.
A well-balanced education can be obtained by diversifyin g sour ces of learning to encompass a th ou ghtf ul mixture of reading book s and journals, att ending lectu res and conferences, and participating in inform al discussions.
One tim e-hon ored approach to continuin g educatio n is to read about th e disorders yo u find in yo ur own patients as yo u encount er them. This exam will help you ident ify areas of strength and areas req uirin g further stu dy.
Such certi fication is based on cont inuing educa tion, licensure, verifica- tion of credent ials by the chairperson of the residenc y pro gram, the Writt en Q ualifying Examination, and the Oral Examination. T he MOC process requi res proof of state licensure, docum entation of continued medical education, office record review, open book practice examinations, and a closed book examinatio n.
Th e pr ocess is repeated every 10 years. Int roduction t o th e Pract ice of Ophthalmo log y 7. Acti ve pursuit of educatio n and tra ini ng must con tinue beyond reside ncy.
T he be- ginning resident must make a commitment to sharpen med ical ski lls and knowledge throu gh continual study, instruction , and exp erience.
Maintain ing co mpetence is essen- tial to the ethical practice of ophthalmology and to the promot ion of int ellectu al and pr ofession al growth. Keeping up wit h medical and surgical disc overi es and inventi ons, whi ch seem to change th e practice of medicine almost daily, is necessary to remain com - petitive in a mark etpl ace that deman ds excellent outcomes. Th e dema nds of healt h care refo rm will affect the challenge of becom ing an excellent ophthalmo logist.
Increasing co nstrai nt s o n the time and econom ic reso urces available for education are furth er st rained by the need to remain cur rent and fully co mpetent in an ever-evo lving field. Th e Ame rican Academy of O phthalmology AAO offers a framewor k of Academ y reso urces that can help memb ers acco mp lish their co nt inuing educat ional goals in the face of new challenges and imp eratives.
Fo r a listing of Academy prod ucts and services, visit the AAO we b site at www. Learn it right the first time. Always cons ult a more knowledgeab le or expe rienced ph ysician if yo u are un cert ain abo ut how to pr oceed in a clinical situa tio n. Adopt a lifelo ng approac h to learn ing. Strive to impr o ve up o n them and be recept ive to criticism. Th e art of pr acticing med icine is best achi eved by a well-rounde d, matu re, and com passionate ph ysician who also knows th e medical facts well.
San Francisco: Ame rican Acad emy of O phthalmology; Basic and Clinical Science Course. San Fran cisco: American Acade my of O pht hal- mology; published annua lly. Code of Ethi cs. American Academy of O ph thalmo log y web site. Accessed May 11,20 Common Program R equirem ents.
Accessed March 15, Durfee DA, ed. The Profession of Ophthalmology: Practice Managem ent, Ethics, and Adv ocacy, 2nd ed. American Academy of Ophthalmology; American Academy of O phthalmology; The purpose of the ophthalmic evaluation is to document objective and subjective mea- surements of visual function and ocular health. The specific objectives of the compre- hensive ophthalmic evaluation include the following:.
Often the patient needs only explanation and reassurance, which is best offered after the examination has been completed; otherwise, the reassurance will not be credible. The ph ysician accomplishes these objectives by obtai ning th e patient's history and performing the necessar y examinations, using specific equipment as needed.
A success- ful encounter also requires th at the physician approach the patient with a professional demeanor. Finally, timely and accurate documentation is important.
History Obtaining a thorough history from the patie nt is the important first step in an ophthalmic evaluation see Chapter 3. In general, the history includes th e followin g information:.
Examination T he co mprehe nsive ophthalm ic evalua tio n includes an anal ysi s of the p hysio logic functi on and anatomical statu s of th e eye, visu al system, and related stru ctures. C om- pone nts of the evaluation and chap ters in th is book in w hich th ey are discuss ed are not ed below:. Ophthalmic Equipment T he op hthalmic examinatio n room and its equipment are someti mes refe rre d to as a lane.
Althou gh the equipment in examining room s varies widely, th e component s typi cally incl ude th e following:. This printed hanging chart, project ed chart , or video display is used in d eterminin g visua l acui ty and in refractio n see C hap ter 4.
This p rint ed handheld chart is used to determine near visual acuity and as an aid in refraction see Chapter 4. Overview of th e Ophthalmic Evaluation These instruments ar e u sed to check pupillar y light r eflexes an d the corneal light reflex. Auxiliar y uses include illumination for th e extern al examination and tr an sillumination of the glo be see Chapters 6, 7, and 9. T his optical mag ni fy ing ins tr umen t is pri m ar ily used to perform anterio r segment exam inations.
It is also used in conjunctio n with a gonioscopy len s to exam ine th e ante r ior ch amb er angl e see Chapters 10, 11, and This devi ce atta ch es to th e slit -lamp biomicro- scope and is used to me asure intraocular pressure. A handheld de vice Tone-Pen can also be used to m easure intr ao cul ar pressure see C hap te r This handheld in strument is used to pe rform reti noscopy, an objective mea surement of a patient's refractive st ate see Chapter 5.
Practical Ophthalmology: a survival guide for doctors and optometrists
This device also called a refractor sto re s a ran ge of trial len ses, It is used when performing r et inoscopy and refraction see Chapter 5. This equipment is used wh en p erforming r etinos- copy and re fr action and to confirm refractive find ings see C hapter 5.
It is als o useful when performing tests evaluating ocular alignment of a patient w ith o u t his or her glasse s. This handh eld dev ice is used to m easure vert ex d istanc e, w hich is the distance between a patient's eye and the back surface of a spectacle lens see Chapter 5.
This handheld instrum ent is u sed for post erior segment examinations and also to assess the red reflex see Chapter This de vic e, w o rn o n the head, is used fo r th e posterior segment examination in conjunction with auxiliary handheld diagno stic conden s- ing lenses see Chapter This d evic e me asures co rn eal curvature and is typically used when fitting contact lenses and to diagnos e disorders suc h as keratoconus.
These optical devices, available individually or held togeth er in a prism bar, are used to me asu re st rabismus see Chapter 6.
The Worth 4-dot testing equipment consists of red -green eyeglasses and a flashligh t that illu m inates 4 colored dots. The Titmus test utilizes a stereoscopic test booklet and a pair of polarized spectacles.
Both of these test s ar e used to assess binocula r vision as a p art of the motility examination see Chapter 6. Standardized books of colo r ed plates, su ch as th e Ishihara p seudoisochromatic color tests, are used when congenital or acquired colo r vision defects are sus p ected see Chapter 4.
This ins trument is us ed to assess the ante rior-pos terio r p osition of th e glob es by measuring the distance from the lateral orbital rim to the corneal ape x see Chapter 9. Ancillary Equipment Other equipment is com monly used to measure visual func tion or to assess ocular structures:. This device is usually automated, but it may be manual. It is used for assessing the central and peripheral field of vision see Chapter 8. This automated system is used for measuring corneal curvature.
It is most useful in refracti ve surgery, after corneal transplant surgery, and in evaluating patients with keratoconus. This system provides a high-resolution cross-sectional image of the optic nerve and retina. It is useful in evaluating retinal disease such as macular edema and in monitoring glaucomatous nerve disc changes.
OCT can also be used to visualize anterior segment structures. This imaging moda lity provides 1- or 2-dimensional cross- sectiona l views of the eye. This device is used to evaluate the corneal endothelium. It demonstrates cell morphology and calculates endothelial cell density see Chapter This instrument is used to measure corneal thickness.
It may be found as a slit-lamp attachment or as a handheld device. Physician Demeanor and Approach to the Patient When performing the ophthalmic evaluation, the ophthalmo logist's approach to the pa- tient should be compassionate and pro fessional. He or she shou ld listen to patients' con - cerns carefully and with undivided attention. Patients' descriptions of ocular problems, in their own words, are of vital importance.
Afte r completing the ophthalmic evaluation and counseling the patient, it is advisable to ask if the patient has any additional ques - tions or concerns and to address them at that time.
As in any medica l setting, it is impor- tant to mainta in the confidentiality of all patient informa tion and interactions. Certain situations can create barriers to effective patient-physician communication. When the patient and the ophthalmologist do not speak the same language, bilingual family members or staff can often bridge the communication gap by trans lating for the patient and physician.
If a trans lator is needed to obtain informed consent for a procedure, it is advisable to consult hospital administrative staff regarding institutional po licies. In these situations, family members might not be permitted to be the sole trans- lators, particularly if they are minors. In some situations, the menta l status of the patient limits the extent of first-person history taking. In these cases, the family members, guardians, or attendants of the pa- tient can usually provide additional important information.
By creatin g an atmosp here of trust, resp ect, and openness, the ophthalmologist can enco urage th e patient to communi cate freel y, and effective patient- physician co mmu nication can be ach ieved. Pediatric Patients Pediatric pa tients w arr ant special conside rat io n. The par ent o r caretake r w ill be the pr i- mary sou rce of info rmation for preverbal children.
Ol de r child ren shou ld be inv olved as much as pos sible in histo ry takin g and in discussi ons of the findings and treat ment p lans, dependin g on th e child's age an d ability to communicate and co mp rehen d.
Elderly Patients O phtha lmologi sts typi cally int eract with patients of all age gro up s, many of w ho m are elde rly. With advan cing age comes an increased prevalen ce of major causes of visual imp airment eg, diabet ic retinopa thy, glauco ma, cataract, and age-related macul ar de- generation. T he op ht halm ologist-in-trainin g needs to give sp ecific co nsideratio n to the special ne eds and impac t of visual loss in aged pati ents.
The wo rd "s enile," as in senile cata ract, is we ll established in med ical termin ology, but this word has unp leasant co nnotatio ns and sho uld no t be used in the presence of pa- tient s. In volutional o r age-related are far pr efer ab le if an eq uivalent adjective is nee de d. Lo ss of visual fu nction increases the incidence and severity of falls and frac tures. Pre ven ting falls is a much mo re effective strategy th an treati ng th em.
Possible intervent io ns for reducing th e risk of fallin g include th e fo llowing:. Visu al loss an d hearing imp airment often coex ist, and th e p resen ce of both sen so ry deficits is wo rse than eithe r o ne alo ne. Op ht halm ologists sho uld reco gnize hear ing- imp air ed patients and refer them as needed fo r manageme nt. Visu al loss is also commonly associa ted wi th depression , especia lly in elderly patient s.
D ep ression sho uld not be overloo ked or ignored, as it is a deb ilitating, yet tre at ab le, co n- dition. Patient s rarel y tell th eir ophthalm ologists th at th ey are depressed, and they oft en do not reco gn ize their o w n depressio n. The o ph thalmologist may simply ask , "Do yo u feel sad or depressed? Loss of visu al cues can wo rse n sym p toms of dem enti a, and visual impa ir ment is asso ciated wi th Alzhe im er's d isease.
One such test is the" clock draw. Pati ents wh o fail th e test shou ld have evalu- ation for pos sible dementi a. Visual loss can have profound effects on many activities of daily living, such as walk - ing, going outs ide, getting in and out of bed, groc ery shopp ing, paying bills, cleaning hou se, answering th e teleph on e, cooking, and driving. Many of these problems can be help ed by low- vision evaluation and tr eatment using optical and nonop tical rehabilita- tive aids.
One of the most simpl e, comm on, and useful aids is a high-plus reading pr e- scription th at serv es to magnify reading material. Social, family, commun ity, and other support services often improve the visually impaired patient's qual ity of life. Th e ophthalmologis t may be called upon to make reco mmendat ions to licensing agencies for candidates who do no t meet the criteria for an unr estricted dr iver's license.
Some states now require vision testing for elderl y dri vers at the time of license renewal. Altho ugh visual acuit y may be th e sole criter ion of visual function measured in many states, visual acuity alo ne is a poor pr edicto r of at-fau lt crash invo lvement. Safe dr iving requires the motor abilit y to scan a rapidl y changing envir onm ent and to react in a timel y fashi on, the senso ry ability to perceive info rmat ion in the rapidly ch anging environment, th e atte nt iveness to process multiple pieces of information, and the cognitive ability to judge this infor mation and make appropriate decision s.
Th e license to dri ve a car on public ro ads is a pri vilege rather th an a right. Ophthalmol ogists sho uld be familiar with th e dr iving requ irement s of thei r indi vidu al sta tes. Medical Record Keeping Timely, legible, and tho rough docum ent ation of the opht halmic evaluation allows the ophthalmo logist and ot her caregivers to refer to the data in th e fut ure and thu s is of treme ndous importance to patient care and continuity of care.
Many oph thalmo logists now use an electronic com puteri zed med ical record, and advant ages of such a system include improved legibility, accessibilit y from multiple sites, and red uced space require- ments for sto rage.
Alt hou gh som e abbreviation s are widely used, ophthalmologic med- ical record s sho uld be w ritte n using term inology that will be und erstand able to other health care providers who will access the med ical recor ds. Excessive use of jargon sho uld be avoided. As a medicolegal document, the medical reco rd must pre sent sufficiently detailed findin gs and tr eatm ent reco mmen dation s.
Th e record mu st be sufficient ly com- plete to justify coding levels fo r charges and reim bur sement. C omm uni cation with referrin g physicians and other health care pro viders, w hether w ritten or verba l, is cruci al in providing the pa tient wit h continuit y and coo rdina tion of care. Such commu nicat ion should be clear, timely, and informative. Overview of the Ophtha lm ic Evaluat ion Some ocu lar condi tion s occur as mani festations of systemic d isea ses that consti tut e a threat to p ub lic hea lth, su ch as gonococcal co njunctivi tis and oc u lar infections related to human imm unod eficiency virus.
Som e such d iseases, by sta tutory guid elin es, mus t be re- ported to th e state h eal th dep artment. State s also oft en want reports abo ut p atients w ho have rece ntly become legally blin d. Rep ort ing gu ide line s vary fro m state to state; oph - thalmolo gists sho u ld con tact th eir sta te h ealth d ep artm en t for app rop riate gu id elines.
In this wa y, ke y historic poin ts or exami nat ion finding s are much less likely to be omitted. T his reacti o n is norm al. A me rican Aca dc my of O phth alm olo gy; 20 The Profession of Ophthalm ology: Practice Mana gem ent, Ethics, and Advocacy, 2nd ed. American A cad emy of Opht ha lm o logy; 20 M iller AM. Ac ccssed May 11, 5. Movagha r M, L aw re nce M G. Ey e exam: San F ranc isco: Am eric an A cad em y of O p hth almol ogy; Rev iew ed for cur rency Am eric an Aca demy of Oph thal mo log y; Pedia tric Ophthalm ology and St rabismus.
Basic an d C linic al Science C our se, Secti on 6. Am eric an Ac adcm y of Op hth almo log y; p u b lished ann ua lly. Vision R equirements fo r D riving [Po licy Stat emen t]. Amcrica n Acade m v of O p ht ha lmology; Although si mi lar to th e gen er al med ical h istory that you learn ed in medica l sc ho o l, the op hthal mi c h istory emp hasiz es sy m p to ms of oc u lar d isease, p resent and p ast ocular problem s, an d o cula r m edi cations.
The h isto ry is intended to elicit an y in form ation t ha t mi ght be useful in eva luat in g and managing th e patient; it ma y be as br ief o r as ext ensi ve as required by th e p ati en t' s particul ar pro ble ms.
This chap ter prov ide s an overview of the op htha lm ic histo ry, its goals, recording me t ho d s, and co mponents. Goals of the History T he hi st o ry shou ld allow fo r th e re co rdi ng of impo rta nt inf or m at io n t ha t cou ld affec t the p ati ent 'Sd iagnosis and tre atment.
T he 5 mos t im p ortant o bjec t ives includ e t he fo llowing:.
Ident ify the patient. If not alrea dy coll ected, reco rd d em o graphic info r mat io n about t he pa tient, su ch as nam e, add res s, d at e o f birth , se x, race, a nd med ica l reco rd number. Identify other practitioners ,zdJ O have cared for the patient 01' ubo may carefor the patient in the f utu re. Su ch ind ivid ual s might need to be con tacted fo r ad d itiona l in formation or be given in for m ation abou t th e p ati ent, esp ecially if t he p atient wa s referred for cons ultation, in w hi ch case a writt en rep ort is req u ire d.
Reports also arc o ften ne ed ed foll o w in g referrals from attorneys, in suran ce co m p anies, o r go ve rn m ental ag enc ies , 3. Obtain a prelim inary diagnosis. Th e likely d iagnosis , or at least a reasona ble d if - fe r ent ial di agn osis, can o fte n be suspec te d m er ely o n t he basis of a good history.
T his, in tu rn , allo w s for the p lann ing an d tailo ri ng of a mo re usefu l and efficient exa mi natio n. Select therapy, K no win g and record ing t reat m en ts that have alrea dy b een tr ied , an d w he th er or not a nd in w hat way s th ey we r e help ful , is inval uab le in p lannin g t herap v for th e fu ture.
A n aw k w ard situ at ion ca n ar ise if a ph y sician recommends th erap y, o nly to learn t ha t the sam e therap y has alread y been tri ed and has failed. Insufficient knowled ge o f th e res ults of p rior th erapeutic effo rts can also lead to m isd iagn osis. T h is can be d one d ir ectl y by q uest ioning the patient o r, in man y cases, ind ircctl y by list ening att entively to,. Some patients require definitive therapy, whereas others need onl y explanati on and reassurance, documentation of a prob- lem, or periodic ob servation.
Consider socioeconomic and m edicolegal facto rs. Insurance payments, worker's compensation payments, disab ility payments, and the like on the patient's behalf , as well as legal proceedings, often depend on detailed, accurate reports or even testimony from th e ph ysician.
Such reports can be inadequate and sometimes even humiliating for the ph ysician if a thorough history has not been obtained. In addition, a well-taken history can save time and expens e by ob viatin g needl ess tests and examination procedures. Such efficiency and cost containment is impor- tant in the curr ent environment of cost -containment. Also, the components and thoroughness of the history are considered and may be audited by payors eg, Medicare to determine the appropriateness of coding and charges for ser vices.
Methods of Recording the History The preci se method of recording the history depends on the requirements of the practice or institution. Th e history may be hand written on blank paper or on a preprinted form, dicta ted for later transcription, or entered into a computerized database. Components of the History As described below, the components of the ophthalmic history are essentia lly the same as the components of any general medical history, except that ophthalmic aspects are emphasized.
Th e components of the history are the follo wing:. Chief Complaint The patient's main complaintis should be recorded in the patient's own w ords or in a nontechnical pa raphrasing of th e patient's words. It is not advisable in this early phase of the history for the ophthalmologist to draw hast y conclusions by employing medica l terms that suggest pr emature diagnoses. Th e ph ysician 's impression is appropriate only later, after a pro p er h ist or y has been take n and a suitably thoro ug h examination has been p erfo rmed.
O f co urse, patient s are sometimes troubled by more than I sy mptom or prob lem and so might have mo re tha n 1 chief co mp laint. Pr o blems that are of lesser importance shou ld be cited alo ng with the chief complaint.
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H ere arc so me examples of t he kin ds of questions that can help to elicit th e pati ent 's main complaints:. T his typ e of q uest ion so metimes reveals ent irely un founded fears , suc h as b lind ness o r cancer.
History of the Present Illness Evaluation of the p atient 's pre sent illness co nsists main ly of an effort to reco rd add itiona l inform ation and d etails abo ut the chief complaint s. The patient's own word s may be used here w hen des ired, altho ug h the ph ysician's wo rds, includ ing med ical termino logy and abb reviatio ns, are mo re often used to rep rese nt wha t the patient said.
Information elicited abo ut the p resent illness allows the op hthalm ologist to begin develop ing a pre- liminary diagn ostic imp ression. T he fo llowin g gene ral areas of inqui ry are given as suggestions for developing infor- mati on abou t th e pr esent illness.
Was it sudde n or grad ua l? H as the pr obl em imp roved, worsened, or remained the same? What migh t have pr ecip itated the condition , made it bette r or worse , or made no difference? Ask ing about p rior therapeut ic effo rts is esp eciall y impor- tant , and it is helpful to know when the patient 's refractive p rescrip tion wa s last changed.
H as the prob lem bee n inte rmitte nt or seaso nal, or d oes it worsen at a p arti cu lar time of day? If so, were th er e an y influe nces that see med to p recip itate exacerbations or remissions? Is th e p rob lem uni later al or b ilateral? It is so metimes nece ssar y to clarify wh at th e patient mean s by cert ain complaint s.
Fo r example, do es " matt ering" of th e ey e mea n sea ling of the eye lid s by sti ck y d isch arge, the mer e p resence of st rands of mucu s at ti mes , or simp ly the noting of tin y granules on the eye lids as from dried muc us o r the dr ying and cr ystallizat ion of eyed rops?
Old records, or even old photographs, can be of value in doc - umenting the presence or absence of particular problems in the past eg, ptosi s, abnormal ocular motility, proptosis, facial nerve palsy, anisocoria.
Specific complaints that might be recorded under "History of the Pr esent Illness" are too numerous to list here in their entirety. Nevertheless, one needs to keep in mind certain general categories of complaints, which are listed below together with examples of accompanying specific compla ints.
Trauma Cases of ocular tr aum a in part icular can require very detailed repo rt s based on a tho r- ough histo ry and examin ation. For mcdical, mcdicolegal, and co mpen satio n purposes, it is impo rtant to obtain the following information:. Past O cular History Prior ocu lar problems can have a bcarin g on a pa tient's statu s.
You sho uld ask the pat ient about the existe nce of any such probl ems so that their po ssibl e role in th e pres cnt illness can be evaluat ed, and so that th ey can bc managed, if neccssar y. To begin with, th e patient is usually asked simp ly if there have been any eye p rob- lems in the past, but it is often useful for elicitin g additional inform ation to ask about the following:.
If the patient respon ds po sitively to any of th e above, it might be valuable to ask why, when, how, w here, and by whom, as app licable. Ocular Medications Kno wledge of the patient 's use of ocular medications is essent ial. It is necessary to know how th e patient respo nded to prior th erapy. In addition , recent therapy can affect the patient 's present status, because toxic and allergic reaction s to topica l medic ations and p reservatives som etimes resolve slowly.
All current and prior ocu lar medic ations used for th e present illness should be recorded, includ ing dosages, frequ ency, and duration of use. Also ask about the use of any over-t he-cou nt er no nprescription medicatio ns, home remedies, herbal medicines, and dietary supplements. Patients sometimes do no t kn ow the names of their medication s. In such cases, th e physician might learn the general classes of medicati on s being used by asking the color of the cap on the container, because some containers for eyedrops have caps of different colors to facilitate ident ification:.
General Medical and Surgical History The patient 's p resent and past general medic al history is imp ortant fo r 2 reason s.
First, many ocular diseases are manifestations of o r are associated with sys temic diseases. Second, th e general medical status mu st be known to perfo rm a pr oper preop erative evaluati on. All medi cal and surg ical pr o blems sho uld be reco rded, along with the approximat e dates of onset, medica l trea tments, o r surgeries when possible. D iabetes mellitu s shou ld be identified as insulin dependent or non-insu lin depe ndent , and th e du ratio n of dia be- tes should be determined.
T he adequacy of glycemic co ntro l is imp o rtant information to acqu ire. Previous history of and tr eatment for sexually tr ansmitted dise ases can be pertinent in cert ain situa tions.
Th e evaluation of a pediatric patient might req uire obtaining historic informatio n from the mother abo ut pregnancy p renatal care, drugs used, complications in labor, prematurity, del ivery, birt h weight, and th e neo natal period. Systemic Medications System ic medicatio ns can cause ocular, pr eop erat ive, int rao perative, and postop erative problems and can provide clues to system ic disorders th e patient might have.
Part icu lar attention sho uld be given to t he use of aspirin and other ant icoag ulant agents, as they can cause int raop erative and po stoperative bleeding. Th e patient 's use of system ic medi- cation s eg, acetazo lam ide, vitamins th at are taken for ocular prob lems may be record ed here or, preferably, und er "Ocular Medications.
Certain medicines, suc h as ant imalari als, phenothi azin es, amiodaro ne, tamoxifen, and systemi c steroids, can have ocular toxicity. Patients may also be taking alternative medi- cations, herbal co mpound s, and vitami ns th at should be no ted here.
Alle rgies The p atient's histor y of allergies to medication s is impo rta nt. However, patients oft en cannot differenti ate tru e allergic reactions from side effects o r other non -allergenic adver se effects of medication s, so it is importa nt to ask abo ut and record the natu re of any claimed reac tio n.
Itching, hives, rash es, w heezing, or frank cardiorespirato ry collapse clearly suggest tr ue allergy, where as statements such as " the d rop s burned " or "t he p ills upset my sto mach " do not.
In additio n to inq u iries about allergic reactions to topical and sys temic medication s, the physician sho uld ask about allergies to environmental agents atopy , resu ltin g in any of the followi ng:.
In some instanc es, the pre sence of th ese kinds of disord ers might alread y have been elicited in the taking of the pr esent illness, past medical histo ry, or review of systems, in which case it need not be again recorded und er "All ergies.
Social Hist ory A social history should be tak en, including information on such matters as tobac co and alcoh ol use, drug abus e, sexual history including sexually transmitted diseases , tattoos, body-piercing, and enviro nmental factors. A det ailed occupational histo ry should be taken to include th e visual requirements of the pati ent's job and hobbies.
As man y jobs have specific visual requ irem ents eg, commercial truck driv er, law enforcement officer, pilot , this information is vital. The questioning should be pursued in a nonjudgmental way, with sensitivity and due respect for privac y. Except as might be req uired by law, or with the patient's permission, such information should not be revealed to third parti es.
Family History The family history of ocular, or nonocular, diseases is important when genetic ally trans- mitted disorders are under consideration. The physician might begin by asking a general question such as, "A re there any eye problems, other than just needing glasses, in your family history? Knowledge of familial systemic diseases can be helpfu l in ophthalmic evaluation and diagnosis.
Examples include atopy, thyroid disease, diabetes mellitus , cert ain malignan - cies, various hereditary syndromes, and many others. Inability of the patient to provide information about the famil y medical background should not be construed or recorded as a negative family history. Rather, the chart should reflect the fact that the pati ent's knowl edge was incomplete or lacking. Exami nation of family members can be usefu l when pati ents present with possibly heritable disorders.
Review of Systems A pertinent review of systems, tailored to the patient's complaints, should be conducted, including questions abou t diabetes mellitus , hypertension, and malignancy, as well as dermato logic, cardiac, renal, hepatic, pulmonary, gastrointestinal, central ner vous sys- tem, and autoimmune collag en vascular including arthritic diseases.
The history need not be of great length, but it should contain all the details that are pertinent to the patient's com- plaints and prob lems.
Hist ory Taking Parent s, gua rdians, ot her relatives, o r friend s ar e som et imes need ed to give his- tories for patients w ho ar e un abl e to speak fo r themselves. A n int erpreter can be invaluab le for an y pa tient w ho docs not spea k the ph ysician 's lan guage.
A good histo r y may be brief or lengthy, as lo ng as it is thorough relat ive to th e ult imat e goa l of help ing the patient. The ability to take an essentially complete, ye t efficient , history is an impo rt ant aspec t of the art of me d icine.
N evert heless, th e begin ning op ht halm olo gy resid ent w hose histories fall short of bei ng idea l should not be d ism ayed; the skill imp ro ves grea tly with practice.
Suggest ed Resources Fundamentals and Prin ciples of Oph thalmo logy. Basic and C linical Science C our se, Section 2. A merican A cad emy of Ophthalmology; pu blishe d ann ua lly.
Practical Ophthalmology: A survival guide for doctors and optometrists is a book aimed at primary care, junior doctors, medical students, and optometrists. It aims to provide the reader with a practical and assessable guide, which aims to guide the reader towards the diagnosis, management, or referral by means of flow charts and lucid text. It then briefly discusses a host of other ocular complaints including flashes and floaters, visual distortion and visual field loss.
It provides a list of critical points about all these condition in the starting of the book and then repeats them at the start of each section. This book in brief, therefore, provides a trainee with a quick ready-made examination plan, which will provide them with a plausible list of differential diagnosis.A p rism me asuring 1 p rism d io pter deflects a lig ht ray 1 cm at a di stance of 1 m.
It also describes ways in which th is book can help yo u in your first few mo nths of residency and beyond if you w ish and offers pr actical tips on dealing with some of th e challenges yo u will face.
Some such patients believe, correctly or otherwise, that they will go blind. In some instanc es, the pre sence of th ese kinds of disord ers might alread y have been elicited in the taking of the pr esent illness, past medical histo ry, or review of systems, in which case it need not be again recorded und er "All ergies.
A well-developed support system should help in this re- spect, and you should not hesitate to convey to the appropriate supervisors any concerns you might have about situations or events that interfere with your effectiveness or well- being. Committee Samu el P. Occasio nally, as with patient s who are bedridd en or w ho are examined in the emerge ncy room , near vision testin g might be the onl y available metho d of measuring visua l acuity.
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