Ophthalmology History Taking
1. PC
2. HOPC
P attern (mono/binocular, onset (sudden/ gradual), duration, part of vision affected, hx)
P ain/ redness/ itch/ discharge
P roblems reading
3. Associated Sx
P hotophobia - "Do lights bother you?"
F lashes (RD, acute angle glaucoma)
F loaters (PVD, RD)
F ield
F ade ("Do you notice colours fade to gray?" = optic neuritis/ hypoperfusion (amaurosis fugax/ postural hypotension, shock, hyperventilation --> hypocapnia, high G forces))
Metamorphosia - "Do you see any distortion?" (ARMD)
GCA sx
Sexual hx (HSV keratitis, syphilis)
Autoimmune (Iritis, episcleritis)
4. PMHx
? DM (DR)
? HTN (HR)
? CVS (occlusion)
? Melanoma
? HIV
5. Past ophthalmic Hx
- Corrective lenses?
- Surg?
6. Meds/ Allergies (?toxicity)
7. FHx
? Glaucoma
? RD
Ophthalmology Examination
Source
Fletcher Ng 2014
1. PC
2. HOPC
P attern (mono/binocular, onset (sudden/ gradual), duration, part of vision affected, hx)
P ain/ redness/ itch/ discharge
P roblems reading
3. Associated Sx
P hotophobia - "Do lights bother you?"
F lashes (RD, acute angle glaucoma)
F loaters (PVD, RD)
F ield
F ade ("Do you notice colours fade to gray?" = optic neuritis/ hypoperfusion (amaurosis fugax/ postural hypotension, shock, hyperventilation --> hypocapnia, high G forces))
Metamorphosia - "Do you see any distortion?" (ARMD)
GCA sx
Sexual hx (HSV keratitis, syphilis)
Autoimmune (Iritis, episcleritis)
4. PMHx
? DM (DR)
? HTN (HR)
? CVS (occlusion)
? Melanoma
? HIV
5. Past ophthalmic Hx
- Corrective lenses?
- Surg?
6. Meds/ Allergies (?toxicity)
7. FHx
? Glaucoma
? RD
Ophthalmology Examination
- Inspect (bedside, general, lids, pupils, sclera)
- Palpate (hard = glaucoma)
- CN II, CN III
- Slit Lamp
- IOP (Tonometry - N: 10-21mmHg)
Source
Fletcher Ng 2014