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ORIENTATION_ HISTORY TAKING _ EXAMINATION

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ORIENTATION_ HISTORY TAKING _ EXAMINATION Powered By Docstoc
					      ORIENTATION, HISTORY TAKING & EXAMINATION
                    Dr. Yasser Al-Fakey
                M.D., M.Sc (Ophth.), FRCS


Attendance and participation in Lectures & Tutorials
Aiming to have solid knowledge wise and guiding you to work your way
through the course.
You should have a minimum of 75% attendance to be eligible to take the
examination.

Attendance in the Outpatient Clinics
What are the common instruments and tools used in the clinic?
How to use the instruments?
What is the normal?
Pay attention to the C/O and physical examination, then correlate them
with the diagnosis.
Ask, ask and ask the attending consultant; discuss with him the clue for the
diagnosis and possible D.D.
Respect the patient.

Attendance in the OR
You will be allowed to attend the OR to be familiar with the setup.
Open discussion as regard common surgical procedures.
Memories the indications, crucial steps and complications.

Continuous assessment and Final Examinations
OSCEs
Multiple Choice Questions.
                         HISTORY TAKING


Two types of patients entering an ophthalmologist’s office:
    1- Who desires routine ocular examination combined with refraction.
    2- Patients with symptoms of ocular diseases.

Organization of History
Personal data.
Chief complaint & its duration.
History of present illness.
History of past health.
Medications.
Allergies.
Family history of ocular disorders.

Personal Data
Name.
Age.
Sex.
Medical Rec.#.
Marital Status.
Residence.
Occupation (type of work & industrial hazards).
Special Habits ( smoker, alcoholic, drug addict …. etc.).


Chief Complaint & its duration
Headlines of any ophthalmic history.
In a sentence or two, You should write down the main reason for which
the patient has come for advice & help.
How do your eyes trouble you?
Specify date of onset, cause and duration.

History of Present Illness
Main symptoms with greater detail.
When did the problem begin and under what conditions?
Was the onset slow or rapid in development?
Did it affect one or both eyes?
Did he receive any medications?
What aggravate it & what made it better?
Course of symptoms.
Visual Symptoms
Blurred vision secondary to an error of refraction:
            1- For close work.
            2- For distance work.
Blurred vision secondary to organic disease:
            1- Loss of central vision.
            2- Distorted vision.
            3- Night blindness (Nyctalopia).
            4- Visual field loss, ascending veil.
            5- Transient gray -outs of vision.
Blurred Vision due to media opacities:
            1- Cornea (infiltrations, oedema & scar).
            2- Anterior Chamber (inflammations, hge., infiltrations).
            3- Lens (cataract).
            4- Vitreous opacities.
            5- Epiretinal membranes.

 Diplopia
Double vision (two objects instead of one).
Binocular (weak or paralyzed extraocular muscles) or Monocular (cataract,
subluxated lens or extra pupil).

Red Eye
Unilateral or Bilateral.
Onset, duration & course.
Associated symptoms (discharge, Lymphadenopathy, blurred vision…etc)
Differential Diagnosis:
     1- Acute Conjunctivitis.
     2- Acute iritis.
     3- Acute angle closure glaucoma.
     4- Corneal trauma or infections.

Symptoms (cont.)
Discharge (watery, mucopurulent, purulent and mucoid).
Headache.
Pain.
Asthenopia.
Floating spots and light flashes.
Tearing.
Abnormal appearance.

History of Past Health
Significant medical illness: Diabetes, Hypertension, Cardiac disorders and
arthritis.
Previous eye disorders (same eye or fellow eye).
Contact lens.
Previous surgery: Ophthalmic surgery.
                   General surgery.

Medications
Any medications that the patient may be taking either systemic or topical.
If he can’t identify the medications (common), you can ask the purpose of
the medications.
Antiglaucoma therapy.
Hypoglycemic therapy.
Other medications (for Preoperative assessment).

Allergies
Drugs (taken internally or applied topically).
Inhalants (dust and pollens).
Contactants (cosmetics and woolens).
Ingestants (food allergies).
Injectants (tetanus antiserum).

Family History of Ocular Disorders
In particular: Myopia, Strabismus, Glaucoma and Blindness.
A negative family history does not rule out a genetic familial propensity
(they do not know or reluctant to confess to any weak in their families).
Others (migraine, keratoconus, retinitis pigmentosa,
retinoblastoma….etc.).
                          EXAMINATION

Eye and systemic diseases: Ophthalmic diseases can be a
      manifestation of a systemic disease or reflected systemically.
Human being has two eyes. So, if you missed one eye = ½ diagnosis &
treatment.
            OD (oculus dexter) right eye.
            OS (oculus sinister) left eye.
            OU (oculus uterque) both eyes.
Systematic examination.


VISUAL FUNCTION

Visual acuity:
            1- Distance vision.
            2- Near vision.
Color vision.
Visual field:
            1- Kinetic perimetry (Confrontation method, Goldmann
     perimeter…etc.).
            2- Static or automated perimetry.

Visual Acuity (VA)
It is a measure of the ability to discriminate two stimuli separated in the
space.
The normal eye can distinguish two points separated by an angle of 1
minute to the eye.
20 feet or 6 meters (20/20 or 6/6).
Numerator = distance from the chart.
  Denominator = person with normal vision.
Pinhole effect.


EXTERNAL INSPECTION

Symmetry of the orbits, lid margins, conjunctiva, lacrimal apparatus,
sclera, cornea, iris, pupil and lens.
Use penlight and you may need to hold the upper lids.
Assessment of ocular movement in all positions of gaze.

Symmetry of Orbit
Proptosis (exophthalmos), eye protrusion or Enophthalmos, eye retraction.
Hertel exophthalmometer is used for measurement of degree of proptosis.

Eyelids and Lid margins
Examine the eyelids for signs of Ptosis, Retraction, Inflammation, Trauma
or tumors.
Lid margin position, Puncti, Rubbing lashes or Blepharitis.


SLIT-LAMP

Conjunctiva
Bulbar, Palpebral, Fornices and Caruncle.
Inspect the eye for any discharge.
Palpate the pre-auricular lymph nodes.
Hold eyelids to examine the bulbar conjunctiva and evert the lid to
examine the palpebral conjunctiva or even double enversion of the lid to
visualize the upper fornix.

Lacrimal apparatus
Inspection of normal anatomy.
Dynamics of eyelid closure.
Marginal tear strip.
Tear film Break-up time (BUT).
Schirmer’s test.
Dye disappearance test.
Regurgitation test.
Rose Bengal test.
Probing and irrigation.


Sclera
Sclera is visible beneath the conjunctiva as a white, opaque, fibrous
structure.
Thinning (scleromalecia), Scleritis, Episcleritis and scleral rupture.
Cornea
Slit-lamp biomicroscopy.
Fluorescein stain.
Rose Bengal stain.
Corneal sensitivity.
Keratoscopy (Placido disc, Topography).
Corneal scraping.

Iris and Pupil
Slit-lamp examination (architecture of the iris, patches of atrophy,
synechiae, abnormal opening, mass and neovascularization).
Pupil: R (round), R (regular), R (reactive).
Pupillary light reflex.


Anterior Chamber & Angle Structure
Estimation of depth of anterior chamber, AC, (Eclipse’ sign).
AC reaction in the form of cells and flare (including Hypopyon).
Visualization of angle structure using Goniolens.

Examination of Ocular Muscles
Evaluation in primary position of gaze as well as in cardinal positions of
gaze.

Crystalline Lens
Cataract is the most common cause of decreased vision successfully
treated in all of surgery.
Pupillary dilatation.
Slit-lamp biomicroscopy.
Red reflex.

Retina & Vitreous
Indirect or Direct Ophthalmoscope.
+90 or +78 dioptre lens, using slit-lamp.
Dilate the pupil.
Dim the light.
Comment up on:          Vitreous (clarity, hge., cells …etc.).
                         Retina (optic disc, macula, retinal blood vessels
                         and retinal background).

				
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