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26 terms

History Taking

STUDY
PLAY
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