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COA: History Taking

Terms in this set (66)

A history should be obtained by
asking a series of organized and specific questions
A history should be recorded
by condensing the patient's story, including pertinent facts
When taking a history on a school aged child, it is important to
get an account of the illness from both parent and child
Which is false?
-A thorough history can direct a physician toward a final diagnosis
-All information given by the patient can be shared with insurance companies without permission
-Statements made by patient should lead the assistant to additional questions
-All pt info is private unless consent form is signed
All information given can be shared with insurance companies.
What is not part of a history?
-chief complaint
-medications
-family history
-visual acuity
visual acuity
The presenting complaint is
the main reason that the patient has come to the office
An example of a question relating to onset would be:
When did you first notice the problem?
The question "Does your head hurt so bad that you have to leave school early" relates to?
Severity
To obtain the most important information about the presenting complaint, you should ask questions relating to:
location, quality, severity, timing, modifying factors,
A symptom is?
A change noticed by the patient
An example of a sign is?
an elevated IOP
A 56 year old patient complains of a sudden onset of double vision. It is important to ask?
Does the doubling go away if you cover one eye?
An old photograph of the patient will be useful to the physician if the patient complains of?
lid droop, pupil abnormality, head tilt.
Your patient has a cut eyelid. It is important to know what caused the injury because:
if the object was organic (plant or animal matter), there is a greater risk of infection
A patient presents with a corneal foreign body, and your supervisor asks how the FB got into the eye. This is important because?
If the particle was under high speed, there might be internal ocular damage.
The patient is not wearing contacts, but would like to fit for them? The most important question is?
Have you tried contacts before?
A 52 year old patient hands you his single vision glasses, the only pair he has. Which of the following is the most important question in determining his refractive status?
Do you wear these for driving or reading?
A patient reports he sleeps in his contact lenses. An important question would be?
What type of lenses are they?
The patient gives a history of having a cataract removed with a laser. You should:
Ask the patient if the surgery was done in a hospital while lying down or sitting up in a chair (to an instrument like a slit lamp)
The patient gives a history of having a laser treatment, but is not sure what it is for? You might discover more by asking.
-All the above (do you have diabetes, did you have cataract surgery, do you have glaucoma?)
The patient states she used to wear contact lenses but went back to glasses. A pertinent question would be:
Why did you stop wearing them?
A 76 year old new patient tells you that he caught astigmatism from his brother when they were children. You should:
Ask him what he means by "astigmatism"
Knowledge of a past ocular injury is needed because:
it might help explain current complaints and findings
A patient states she has a prism in her glasses.. Which of the following is the MOST important question to ask?
Have you ever had surgery to straighten your eyes?
A mother brings in her 4 year old son. The mother says he has a lazy eye. What do you need to find out?
What does she mean by "lazy eye"
An example of a systemic illness is:
cardiac problems
Questions asked of a hypertensive patient should include:
method of blood pressure control, decrease in vision, last blood pressure reading
Questions asked of a diabetic patient should include:
method of sugar control, visual stability, last blood sugar reading
A patient with heart problems:
may have hardening of the arteries in the eye
Knowledge of a patient's breathing or lung problems would be important to know if they patient also has:
Glaucoma
Your patient states he has rheumatoid arthritis. You should now ask symptom related questions to find out if he has:
dry eyes
Sickle cell disease:
is hereditary and occurs primarily in the black population
Sickle cell disease may affect the eye:
because the abnormally shaped cells can block the eye's blood vessels
Knowing a patient's past history of surgical procedures is important because:
it may reveal precautions needed before eye surgery is undertaken
Major infections that can affect the eye include:
HIV, gonorrhea, tuberculosis, and herpes simplex
Your patient is a 4 month old who was born prematurely. Which question will be most important in predicting the occurrence of eye disorders related to prematurity?
Did the baby receive oxygen after birth?
In which of the following ocular disorders would be the most important to know what eye drops a new patient is using?
glaucoma
Which situation poses a potential problem in a patient taking aspirin containing medications?
the patient with a cataract who will be having surgery
While taking the ocular history of a new patient, she mentions that her last ophthalmologist told her she has macular degeneration. This should trigger you to specific ask about which of the following?
vitamin use
A patient taking a diuretic might have might special need during the exam?
frequent trips to the restroom
A patient taking a diuretic probably has which health problems?
heart problems
High blood pressure is frequently treated by:
Beta Blockers
If a patient with glaucoma is to be treated using beta blockers, it would be most important to know if the patient is currently being treated for:
high blood pressure
It is important to know if a patient is on birth control pills because:
It can cause changes in the retina
A patient who has been taking oral steroids for long periods should be evaluated for possible development of:
cataracts
Conditions for which a person might take oral steroids include:
rheumatoid arthritis
Patients often fail to report to use of over the counter medications because:
they consider them to be unimportant and unrelated to eye care.
The patient has said he has no heart problems, but you notice that he is taking two heart medications. For the most complete history, you should:
ask the patient what he takes the medication for
Diabetes medication includes:
insulin injections and "sugar pills"
An example of an analgesic (pain relief) is:
aspirin
Which patient is most likely to be using hormone replacement therapy?
a woman who has had a hysterectomy/oophorectomy
A male patient is going to be scheduled for cataract surgery. Which of the following medication is the most concern?
Sildenafil Citrate: Virgra
Your patient says she is allergic to something common, but cannot remember name. You suggest:
Penicillin, Sulfa, or codeine
Your patient says that beta blockers make him nauseous. This is:
...
Your patient says that erythromycin makes her break out in a rash. This is:
an allergy
Your patient is scheduled to have a chalazion excision. It is most important to know his previous reactions to:
local anesthesia (used in minor procedures)
Your patient is unsure if she has ever had any local anesthia. You could ask if she :
has ever had a numbing injection for dental procedure
Your patient reports an adverse reaction to dye injected for a kidney evaluation. This could affect:
fluorescein angiogram
Knowing a patient's occupation may be important in:
prescribing bifocals/trifocals, deciding what medication to prescribe, knowing the patient's risk of eye injury. (ALL)
A patient's social history would include all the following except:
therapeutic drug use
Your patient has been referred to your practice for cataract surgery. You ask if there is anyone at home who can help the patient instill eye drops. This is part of the patient's?
Social history
The most common ocular disorders that run in families are:
strabismus, myopia, and glaucoma
A 25 year old white woman comes in as a new patient because her mom was just diagnosed with glaucoma. This information:
is a good reason for a full eye exam.
A mother brings in a 2 year old child with an esotropia. Which of the following is significant for the family history?
Does anyone in the family have crossed eyes
Examples of hereditary systemic disease include:
Diabetes, Hypertension, arthritis, cancer.
Which of the following is not potentially a hereditary disorder?
secondary glaucoma
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