Basic history and eye examination
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Transcript of Basic history and eye examination
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BASIC HISTORY AND EYE EXAMINATION
DR. WILLARD BWALYA MUMBI (BSC.HB, MBCHB, PG. DIP. BA, MMED, FCO-ECSA)
CONSULTATION OPHTHALMOLOGISTKABWE GENERAL HOSPITAL EYE DEPARTMENTZAMBIA
26TH OCTOBER, 2016
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DISCLOSURES:
No financial disclosures Sources of pictures:
American Academy series Kabwe General Hospital, Eye Department Stanford Medicine Wills Eye Manual
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HISTORY
TYPES OF PATIENTS THAT YOU WILL ENCOUNTER IN THE CLINIC
1. Patients with ocular symptoms
2. Patients with diagnosis who comes for follow up
3. Patients who desire routine ocular examination and refraction
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STRUCTURAL ORGANISATION OF HISTORY
1. PERSONAL DATA2. PRESENTING COMPLAINTS (P/C)3. HISTORY OF PRESENTING COMPLAINTS (HxPC)4. PAST OCULAR HISTORY (POHx)5. PAST MEDICAL HISTORY (PMHx)6. DRUG HISTORY (DHx)7. ALLERGIC HISTORY (AHx)8. FAMILY HISTORY (FHx)9. SOCIAL HISTORY (SHx)
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1. PERSONAL DATA File # Name Age Sex Marital Status NOK with contact phone
# Residence Contact phone #
RELEVENCE OF THE DETAILS:o 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”
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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)
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HISTORY OF PRESENTING COMPLAINTS (HxPC
Briefly explore and develop the chief complaints
Be concise, focused and chronological
o When did the problem begin
o What happened?
o How was the progression?
o Where one or both eyes affected?
o What treatment was received?
o What are the aggravating factors?
o Course of symptoms.
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Visual Symptoms
Blurred vision Double vision Red eye Itchiness Pain Unable to read small prints
Discharge (watery, mucopurulent, purulent and mucoid).
Headache. Asthenopia. Floating spots and light flashes. Tearing. Abnormal appearance.
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PAST OCULAR HISTORY (POHx) Any ocular medications, surgery, eye
hospital visits
Use of spectacles, contact lenses etc.
Last time spectacles where changed.
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PAST MEDICAL HISTORY (PMHx)
DM HTN HIV RHEUMATOID ATHRITIS ASTHMA CARDIAC DISEASE SCD
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DRUG HISTORY (DHx)
BETA BLOCKERS ANTI COAGULANTS STEROIDS – in steroid responders, causes glaucoma TOPICAL GENTAMYCIN – causes epithelial toxicity
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FAMILY HISTORY (FHx)
Myopia, Squint, Glaucoma Eye cancer Blindness.
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SHx
Occupation
Performance at school
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EXAMINATION
OD (oculus dexter) right eye.
OS (oculus sinister) left eye.
OU (oculus uterque) both
eyes
RE
LE
BE
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VITAL SIGNS
BP VISUAL ACUITY IOP ( 9 – 21mmHg)
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EXAMINATION
1. ADNEXA 2. ANTERIOR SEGMENT3. POSTERIORS SEGMENT
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ADNEXA
ORBITAL RIM EYE BROW EYE LIDS EYE LASHES ORIFICES
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SLIT LAMP BIOMICROSCOPE
“SLIT LAMP IS TO THE OPHTHALMOLOGIST AS THE HOE IS TO THE FARMER”
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PALPATE ORBITAL RIM IN CASE OF #
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MOLLUSCUM CONTAGIOSUM
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PIGMENTED EYELIDS IN SEVERE ALLERGIES
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LOWER LID EXAMINATION
Click icon to add picture
MADAROSIS
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LACRIMAL DRAINAGE SYSTEM
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ANTERIOR SEGMENT
CONJUNCTIVA CORNEA A/C PUPIL IRIS LENS
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CONJUNCTIVA
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BULBAR CONJUNCTIVA INJECTION IN HYPERMATURE CATARACT
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TARSAL CONJUNCTIVA FLIPPED: TRACHOMATIS INTENSE WITH EARLY SCARING
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OSSN (OCULAR SURFACE SQUARE CELL CARCINOMA)- SQUAMOUS CELL CARCINOMA
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CORNEA
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PERIPHERAL ULCERATIVE KERATITIS (PUK)
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CORNEA STAINING WITH FLUORESCEIN: CORNEAL ULCER; DRY EYE SYNDROME
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LMBUS
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LIMBAL STEM CELL DEFICIENCY (LSCD) SECONDARY TO SEVERE ALLERGIC CONJUCTIVITIS
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ANTERIOR CHAMBER (A/C)
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A/C
FEAUTRES TO NOTE:I. DEPTHII. FLAREIII. IMFLAMATORY CELLSIV. HYPOPIONV. HYPHAEMA
IF NORMAL, IT WILL BE DENOTED AS FOLLOWS:
A/C : D/Q (DEEP & QUITE)
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PUPIL
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PUPIL
DIRECT LIGHT REFLEX CONSENSUAL LIGHT REFLEX NORMAL DIAMETER 3mm ROUND
NOTATION: RRTL (ROUND REACTING TO
LIGHT) RELATIVE AFFERENT PUPILARY
DEFECT RAPD
SYNAECHIAE
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CATARACT
KATUBE KASANGA KABALE
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POSTERIOR SEGMENT
VITREOUS: Haziness, cells, h’age
OPTIC NERVE: CDR, pale, blurred margin
VESSELS: aneurysm, Ghost vessels
MACUALR: normal, dull reflex, h’age. hole
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POSTERIOR SEGMENT
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FUNDUS
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OPTIC NERVE HEAD
CONSISTS OF :1. OPTIC DISC 2. NEURORETINAL RIM3. OPTIC CUP
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ABNORMALITIES OF OPTIC NERVE HEAD
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GLAUCOMATOUS OPTIC NERVE HEAD
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GLAUCOMA FUNDUS
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MALIGNANT HYPERTENSION
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PAPILLOEDEMA
RAISED INTRA-CRANIAL PRESSURE
FEATURES:o LOSS OF NATURAL
CONTOURSo MARGINS BLURREDo ELEVATEDo DISC VESSELS
TURNING
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OPTIC ATROPHY
o FLAT o PALE – PAPER
WHITE
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DIABETIC RETINOPATHY
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DIABETIC RETINOPATHY
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MACULOPATHY
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QUIZ