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historia clnica

historia clnica

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historia clnica

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  1. BASIC HISTORY AND BASIC HISTORY AND EYE EXAMINATION EYE EXAMINATION DR. WILLARD BWALYA MUMBI DR. WILLARD BWALYA MUMBI (BSC.HB, MBCHB, PG. DIP . BA, MMED, FCO-ECSA) CONSULTATION OPHTHALMOLOGIST CONSULTATION OPHTHALMOLOGIST KABWE GENERAL HOSPITAL EYE DEPARTMENT KABWE GENERAL HOSPITAL EYE DEPARTMENT ZAMBIA ZAMBIA 26THOCTOBER, 2016

  2. DISCLOSURES:  No financial disclosures  Sources of pictures:  American Academy series  Kabwe General Hospital, Eye Department  Stanford Medicine  Wills Eye Manual

  3. HISTORY  TYPES OF PATIENTS THAT YOU WILL ENCOUNTER IN THE CLINIC Patients with ocular symptoms 1. Patients with diagnosis who comes for follow up 2. Patients who desire routine ocular examination and refraction 3.

  4. STRUCTURAL ORGANISATION OF HISTORY PERSONAL DATA 2. 3. 4. 5. 6. 7. 8. 9. 1. PRESENTING COMPLAINTS (P/C) HISTORY OF PRESENTING COMPLAINTS (HxPC) PAST OCULAR HISTORY (POHx) PAST MEDICAL HISTORY (PMHx) DRUG HISTORY (DHx) ALLERGIC HISTORY (AHx) FAMILY HISTORY (FHx) SOCIAL HISTORY (SHx)

  5. 1. PERSONAL DATA  File #  Name  Age  Sex  Marital Status  NOK with contact phone #  Residence  Contact phone #  RELEVENCE OF THE DETAILS: Patient follow up and case tracing o Guide in making a diagnosis o Notification of relatives in case of any eventuality such as death o In research, retrospective study, helps to trace the file from archives o Make it personal ambition to ensure this demographic data is quality, rough estimate of age is better than “F/A” o

  6. PRESENTING COMPLAINTS (P/C) Headlines of ophthalmic history ( main reason patient has come to the hospital)  Specify laterality(BE, RE, LE)  Specify duration ( avoid writing dates, calculate duration) 

  7. HISTORY OF PRESENTING COMPLAINTS (HxPC When did the problem begin o What happened? o Briefly explore and develop the chief complaints  How was the progression? o Be concise, focused and chronological  Where one or both eyes affected? o What treatment was received? o What are the aggravating factors? o Course of symptoms. o

  8. Visual Symptoms  Discharge (watery, mucopurulent, purulent and mucoid).  Headache.  Asthenopia.  Floating spots and light flashes.  Tearing.  Abnormal appearance.  Blurred vision  Double vision  Red eye  Itchiness  Pain  Unable to read small prints

  9. PAST OCULAR HISTORY (POHx)  Any ocular medications, surgery, eye hospital visits  Use of spectacles, contact lenses etc.  Last time spectacles where changed.

  10. PAST MEDICAL HISTORY (PMHx)  DM  HTN  HIV  RHEUMATOID ATHRITIS  ASTHMA  CARDIAC DISEASE  SCD

  11. DRUG HISTORY (DHx)  BETA BLOCKERS  ANTI COAGULANTS  STEROIDS – in steroid responders, causes glaucoma  TOPICAL GENTAMYCIN – causes epithelial toxicity

  12. FAMILY HISTORY (FHx)  Myopia,  Squint,  Glaucoma  Eye cancer  Blindness.

  13. SHx  Occupation  Performance at school

  14. EXAMINATION  OD (oculus dexter) right eye.  RE  OS (oculus sinister) left eye.  LE  OU (oculus uterque) both eyes  BE

  15. VITAL SIGNS  BP  VISUAL ACUITY  IOP ( 9 – 21mmHg)

  16. EXAMINATION 1. ADNEXA 2. ANTERIOR SEGMENT 3. POSTERIORS SEGMENT

  17. ADNEXA  ORBITAL RIM  EYE BROW  EYE LIDS  EYE LASHES  ORIFICES

  18. SLIT LAMP BIOMICROSCOPE “SLIT LAMP IS TO THE OPHTHALMOLOGIST AS THE HOE IS TO THE FARMER”

  19. PALPATE ORBITAL RIM IN CASE OF #

  20. MOLLUSCUM CONTAGIOSUM

  21. PIGMENTED EYELIDS IN SEVERE ALLERGIES

  22. LOWER LID EXAMINATION MADAROSIS

  23. LACRIMAL DRAINAGE SYSTEM

  24. ANTERIOR SEGMENT  CONJUNCTIVA  CORNEA  A/C  PUPIL  IRIS  LENS

  25. CONJUNCTIVA

  26. BULBAR CONJUNCTIVA INJECTION IN HYPERMATURE CATARACT

  27. TARSAL CONJUNCTIVA FLIPPED: TRACHOMATIS INTENSE WITH EARLY SCARING

  28. OSSN (OCULAR SURFACE SQUARE CELL CARCINOMA)- SQUAMOUS CELL CARCINOMA

  29. CORNEA

  30. PERIPHERAL ULCERATIVE KERATITIS (PUK)

  31. CORNEA STAINING WITH FLUORESCEIN: CORNEAL ULCER; DRY EYE SYNDROME

  32. LMBU S

  33. LIMBAL STEM CELL DEFICIENCY (LSCD) SECONDARY TO SEVERE ALLERGIC CONJUCTIVITIS

  34. ANTERIOR CHAMBER (A/C)

  35. A/C  FEAUTRES TO NOTE: I. II. III. IMFLAMATORY CELLS IV. HYPOPION V. DEPTH FLARE HYPHAEMA  IF NORMAL, IT WILL BE DENOTED AS FOLLOWS:  A/C : D/Q (DEEP & QUITE)

  36. PUPIL

  37. PUPIL  SYNAECHIAE  DIRECT LIGHT REFLEX  CONSENSUAL LIGHT REFLEX  NORMAL DIAMETER 3mm  ROUND  NOTATION:  RRTL (ROUND REACTING TO LIGHT)  RELATIVE AFFERENT PUPILARY DEFECT RAPD

  38. CATARACT  KATUBE  KASANGA  KABALE

  39. POSTERIOR SEGMENT  VITREOUS: Haziness, cells, h’age  OPTIC NERVE: CDR, pale, blurred margin  VESSELS: aneurysm, Ghost vessels  MACUALR: normal, dull reflex, h’age. hole

  40. POSTERIOR SEGMENT POSTERIOR SEGMENT

  41. FUNDU FUNDU S S

  42. OPTIC NERVE HEAD CONSISTS OF : 1. OPTIC DISC 2. NEURORETINAL RIM 3. OPTIC CUP

  43. ABNORMALITIES OF OPTIC NERVE HEAD

  44. GLAUCOMATOUS OPTIC NERVE HEAD

  45. GLAUCOMA FUNDUS

  46. MALIGNANT HYPERTENSION

  47. PAPILLOEDEMA  RAISED INTRA-CRANIAL PRESSURE  FEATURES: o LOSS OF NATURAL CONTOURS o MARGINS BLURRED o ELEVATED o DISC VESSELS TURNING

  48. OPTIC ATROPHY OPTIC ATROPHY o FLAT o PALE – PAPER WHITE

  49. DIABETIC DIABETIC RETINOPATHY RETINOPATHY

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