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Past Ocular History

Prior use of topical ocular pharmaceutical agents is part of a patients _______ ________ _________.

Parents, grandparents, and genetic siblings

Pertinent family history of a patient should include which relatives?

An allergic reaction

A patient describing an experience of getting hives after taking sulfa drugs is providing information about _____ _______ ________.

Chief complaint, present illness, past ocular history, ocular medications, general medical and surgical history, systemic medication, allergies, social history, and family history

Name the nine components of the ophthalmic history.

Because certain medications may affect the eyes

Why is it important to specifically ask a patient about the medications they are taking?

Refer the patient to the ophthalmologist

What is the proper response to a patient's request from the ophthalmic technician for medical advice or a diagnosis?

Chief complaint

What is the term used for the reason for the patient's visit?

Smoking, alcohol, and drug use

What elements are important in social history taking?

Routine info on charts

name, address, DOB, phone #, ect

History of present illness

signs and symptoms

Past Health

prev. eye problems, major surgeries, and sig. illnesses

Medications

OTC, physician prescribed

Allergies

medications, environmental and food

Family history

Diabetes, arthritis and hypertension, pt should be asked about bloodpressure

Family history - ocular

glaucoma, cataracts, strabismus, Amblyopia, ARMD, blindness

Direct Questions

closed and very specific. Short response, typically yes or no

Indirect Questions

open-ended and general. Allows pt to elaborate and does not restrict response

How fast does and average person speak?
How fast can they listen

Speak: 120 words/min
Listen: 400 words/min

Right Eye

OD - Oculus Dexter

Left Eye

OS - Oculus Sinister

Both Eyes

OU - Oculus Uterque

How to determine history of CC

Start, OD/OS/OU, VA affected (blurred, double, dim), paim, discharge, sudden/gradual, intermittent, better/worse, trauma, recent illness, treatement given

Symptom

noticed by pt. Ex. itchy, burning, blurred VA, photophobic

Signs

observed by examiner or pt's family. Ex: slightly misaligned eyes, eyelash turned inwards

How to address senstive issues with Pt

ensure privacy, confident and direct ?s, do not apologize, no judgement, non-patronizing terminology, be patient and proceed slowly

Confidentiality legalities

do not give info about pt unless release is signed, do not give info to pt family without consent

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