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Clinical History

1 General Data Age som e disea se s are mo re

commo n to c erta in a ge groups 20 yr o ld p at ient with b lurr ing of

visio n prob a bly du e to an err or of re f ra ct ion

4

0yr o ld p at ient with b lurr ing of

visio n prob a bly du e topre sbyopi a

7 0 yr o ld p at ient with b lurr ing of visio n prob a bly du e to a catara ct

Sex Nat ional ity som e disea se s are fou nd

mo re commo nl y in certa in ra ce s Open an gle gla ucom a commo n

in bla cks

M yopi a commo n in the yell owra ce

Numb er of a dmissio ns Date an d t ime of a dmissio n

1 Ch ie f Comp la int symp tom of e ye disea se bo ther ing the pat ient; rea so n wh y pat ient sou ght consu ltat ion

Use in fo rmant s ow n wo rds mos t a ccu rate de scr ipt ion of the symp tom

1 History of P re sent Illne ss chara cter ize the symp toms

Onset of si gn s an d symp toms Pre ce ding circums tan ce s to the on set

of SSx Durat ion of SSx Chara cter of SSx Agg ra vat ing Fa ctors

Rel ie ving Fa ctors M e dicat ion s us e d (if an y)

1 Past M e dical History Hyperten sion Dia bete s m ell itus Tra um a Surger y O ther pre vious i llne ss relate d to the

e ye ex. Gla ucom a when you ha ve it,

you ha ve it all you r lif e 1 Fa mi ly History

Dia bete s m ell itus Hyperten sion O ther ocu lar disea se s

*p at ient shou ld b e told to in fo rm o ther f a mi ly me mb er s if s/ he ha s a f a mi lial disea se (e. g. gla ucom a )

Symptoms of Eye Disease

1. Disturban ce of Visio n a. De crea se d visu al a cui ty malabo ang paningin, as in ca se s of c atara cts an d m a cu lar de generat ion

A. Normal B. Earl y catara ct

Subject: Physical DiagnosisTopic: History Taking and Ophthalmologic

ExaminationLecturer: Dr. Silvestre A. Pascual Jr.Date of Lecture: July 29, 2011Transcriptionist: Polkadots Pages: 10

S Y 2 0 1 1

- 2 0 1 2

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C. M a cu lar ho le /d e generat ion D. Late catara ct

b . Abnormal co lor vision e. g . Protan opi a brightne ss of re d an d o ran ge are muc h re duc e d

c. Abnormal visu al fiel ds if a ff e ct in g onl y one e ye, mos t prob a bly = op t ic ner ve prob le m o r a ret inal prob le m , a s in ca se s of ret inal deta ch ment He mian opsi a loss of visio n in hal f of the visual fiel d

Q uadrantan opsi a w ala da w talagang ganitong term

A. He mian opsi a B. Q ua drant in opsi a *

d . Iride scent vision see in g hal os ar ou n dlight (figure 3) usu all y se condar y to co rneal e de ma, wh ich can be ca us e d by i n crea se dintra ocu lar pre ssu re e de ma tran sfo rms the co rnea int omu lt iple prisms brea ks the light yousee hal os

Iride scent vision.

e. Floater s usu all y b la ck bu t m a y com e in other co lors se con dar y to op acit ie s in the vitre oush umo r light str ike s the op a city ca sts a sha dow o n the ret ina

Floater s.

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f . Ph otopsi a see in g f la she s of light ma y be central or se condar y to o ther prob le ms ( e. g . migra ine ) occu rs when there is m e chan ical st imu lat ion of the ret ina

g . M eta mo rph opsi a chan ge in the sha pe of the obj e ct seen, a s in ca se s of ob liqu e a st igmat ism , e de m a of the ma cu lar area, an d fov eal cysts

A. Ob liqu e a st igmat ism B . Ede m a of the ma cu lar area

h. Diplopi a doub le vision

2 . Pa in a. Fore ign body s en sat ion fore ign

obj e ct (e. g . e yela sh ) on the co rnea or con junct iva

Fore ign body s en sat ion

b . Dee p p a in with in the e ye cou ld b e ca us e d by suppu rat ive in f la mm at ion of the e ye

Pus i n the e ye 2 to a co rneal ulcer = dee ppa in

c. Hea da che d . Burn in g , itch in g pat ient with her pe s

zos ter op hthal micus m a y ha ve a bu rn in g , itch in g sen sat ion ar ou nd the

e ye

Her pe s zos ter op hthal micus

e. Pho top h obi a f ear of light be ca us e pat ient ex per ien ce s p a in when ex pos e d to light in f la mm at ion of the str uc ture s in the anter ior cha mb er of the e ye, i.e. anter ior uve it is Irit is in f la mm at ion of the ir is

e ye is ex pos e d to light iris wi ll constr ict the pupi l pa in

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Ph otop hobi a

3. Abnorm al Se cret ion f rom Ey e sType s of s e cret ion

A) La crimat ion produc t ion of s e cret ions of the glan ds that clean an d lub ricate the e ye s. -- a ct ive se cret ion of tear s; in crea se d a mou nt of tear s

B) Epiph ora - is ov er f low of tear s o nt o the f a ce. A clin ical con dit ion that con st itu te s insuffici ent tear film

dra

ina

ge

f rom

the e

ye

s in

that

tear

s will

dra

in

down

the

f a

ce

rather

than

thr

ou gh

the

na

sola

crim

alsys

tem

.It

can

be ca us e d by occu lar irr itat ion an d in f la mm at ion or an obs tr uc te d tear ou t f low tra ct (e ctr opio n, pu n ctal, canal icu lar or na so la cr imal duc t obs tr uc t ion et c.).

-- pa ssive tear in g; b lock in the dra ina ge of tear s

C) Dischar ge a. mucoid re se mb ling mucus , can be ca us e d by aller gic rea ct ion. b . mucopu ru lent - is the e missio n or se cret ion of f luid co nta in ing mucus an d pus , du e t oba cter ial in f e ct ion

ex. con jun ct ivit isc. pu ru lent - wh it ish -yell ow ex ud ate in f la mm at ory pyo gen ic ba cter ial in f e ct ions

ex. A mo ther ma y tran smi t gonorrhea to her ne wbo rn du ring ch ildbi rth; when a ff e ct ing

the in f ant' s e ye s, it is re f erre d to a s op hthal mia ne onat orum .

Ophthl mia Ne onat orum4 . Ph ysical Sign s De scribe d by P at ient s a s Symp toms

A. REDNESS - du e t o swo llen or dilate d b lood v e ssel s, wh ich ca us e the su rf a ce of the e ye to look re d . It a pp ear s re d b e ca us e the ve ssel s in the su rf a ce of the wh ite po rt ion of the e ye (sclera ) be com e enlar ge d an dirr itate d . It is commo nl y ca us e d by e ye in f e ct ions o r in f la mm at ion an d can occu r in diff erent locat ions. The yca us e re dne ss a s well a s possib le itch in g , disc har ge, pa in, or visio n prob le ms .

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B. NEW GRO WTH - an a bn orm al ma ss of t issu e a s a re su lt of ne op la sia, a bnormal pro lif erat ion of cell s. M a y be ben ign, pre -m al ignant (car cinom a in situ) o r mal ignant (can cer ). It can occu r in the co rnea, con jun ct iva, e ye lidset c.

C. ABNORM AL POS ITION OF LIDS the e ye lids are de viate d f rom i ts normal posi t ion.

a. Entr opio n - rolling inwar d of the e yel ids , ma y ca us e a bra sion s of the co rnea an d/o r irr itat ion of the con junct iva. b . Ectr opio n - rollin g ou twar d of the e yel idsc. Ptosis - is a (droopi n g) of the upp er or low er e yel id, som et ime s calle d " la zy e ye "Ca us e s: Congen ital, Aging , Scarr ing , M e chan ical, Aller gic, Fa cial ner ve pal sy, Ant i-can cer treat ment s.

D. ABNORM AL POS ITION OF THE EYES can be dete cte d by re f le ct ion of light on co rnea. (re f le ct ion shou ld b e f rom c enter of co rnea. )

a. Esotr opi a - is a form of s tra bismus(is a condit ion in wh ich the e ye s are n ot prop erl y al igne d wi th ea ch o ther, typicall y involve s a la ck of coo rdinat ion bet ween the extra ocu lar musc le s) in wh ich one or bo th e ye s turn s in war d . b . Exotr opi a - is a form of s tra bismus w here the e ye s are de viate d ou twar d .

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E. PAPILLARYABNORM ALITY a bnormal sha pe s of pupi l or mu lt i-pupi ls. a. Po lyco ria - a path o logical condit ion of the e ye chara cter ize d by mo re than one pupi llar y op en in g in the iris. It m ay be con gen ital or m ay re su lt f rom a disea se a ff e ct ing the iris.

b . Core ctopi a - the disp la ce m ent of the e ye' s pupi l f rom i ts norm al, central posi t ion. It m ay be a ssoci ate d wi th h igh myopi a or e ctopi a lent is (disp la ce ment or mal posi t ion of the e ye' s crystall ine len s).

F.O PACITIES AND DISCO LOR ATION y Opa city is an imp enetra bility to visib le light, includi ng long-ter m ex posu re to u ltra vio let

light, ex posu re to ra diat ion, se con dar ye ff e cts of dis ea se s suc h a s diabete s, h yperten sion an d a dvan ce d a ge, or tra um a (possib ly muc h earl ier ); usu all y re su lts f romdenat urat ion of len s p ro te in. Som e drugs, suc h a s co rt icos ter oids c an in duc e catara ct de vel opm ent.

y Disco lorat ion cou ld re su lt f rom a ser iousdisea se in cludi ng can cer or som eth ing a sminor a s f at igue or e ye stra in. Also c an be ca us e d by a har m le ss b roken b lood v e ssel.

Ophthal mo logic Exa minat ion

1) Visu al Acui tyy the e val uat ion shou ld al wa ys b e gin with visu al a cui ty asse ssm ent to avoid possib le err ors wh ich might

com e f rom o ther a sse ssm ent sy M ea su re s central visu al fun ct ion y Asse sse s the inte gr ity of op t ical me dia, ma cu lar area, an d its ne ural ele m ent sy Te sts are do ne for bo th dis tan ce an d near

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* N ot ice the relat ionsh ip of ci liar y musc le an d len s wh ich are impo rtant compo nent s of a ccommod at ion.

A. Distan ce vision te st - in the n on -a ccommod ate d s tate (f ar sight )- te st dis tan ce of 6 m eter s, ea ch e ye is te ste d o ne at a t ime

- ma ke s us e of Snellen s chart - P inhole test ma y be do ne to d ete ct err ors of re f ra ct ion (in order to el iminate per ipheral ra ys w hate ver the len gth of local len se. It hel ps to co n firm w hether it is a focusi n g prob le m o r non -op t ical prob le m

Ex. du e to a possib le disea se proce ss wi th in the e ye )

B. Near vision te st - in the a ccommod ate d s tate - te st dis tan ce is 35 mm , ma y te st bo th e ye s at sa m e t im e - usu all y do ne on pat ient s >35 y ear s (du e to s t iff ne ss of len s wh ich is relate d to a ccommod at ion )- ma ke s us e of Jae ger s chart G ross Examination

y Invo lve s the gross i n sp e ct ion, an d at t ime s (e sp e ciall y when there is p re sen ce of m a ss) p al pat ion of the external e ye an d its a dnexae

y Anat omic al relat ionsh ips , size an d symm etr y shou ld b e care fu lly obs er ve dy Fami liar ity with n orm al dim en sion s

In sp e ct ion of the Upp er Pal pe bral Con jun ct iva :

Instruct the patie nt to look dow n. Get the patie ntto relax the eyes by reassura nce a nd by ge ntle,as- sured, a nd deliberate moveme nts. Raise the

upper eyelid slightly so that the eyelashes protrude, a nd the n grasp the upper eyelashes a nd pull them ge ntly dow n and forward . Place a small stick such as a n ap- plicator or atongue blade at least 1 cm above the lid margi n (and therefore at the upper border of the tarsal

plate) . Push dow n on the stick as you raise theedge of the lid, thus everti ng the eyelid or tur ning

it i nside out . Do not press o n the eyeball itself . S ecure the upper lashes agai nst the eyebrow withyour thumb a nd inspect the palpebral co njunctiva . After your i nspectio n, grasp the upper eyelashesand pull them ge ntly forward . Ask the patie nt to

look up . The eyelid will retur n to its normal positio n. Do the same steps i n the lower lid .

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Ta ke n ote the fo llowi ng:y posi t ion of glob e in relat ion to lids an d lid a pert ure y posi t ion of lids an d la she sy physical signs: e. g . ma ss , re dne ss , disc har ge, op a cit ie sy co rneal light re f lex - to d et. the relat ive posi t ion of the le f t an d the right e ye in relat ion to right e ye y pupi llar y rea ct ion to light sh ine a light to s ee co nstr ict ion of the pupi l; do ne on bo th e ye s.

Extraocular Muscle MovementTwo te sts: Duc t ion an d Ver sion

1. Duct ion y te sts fo r 6 car dinal dire ct ions of ga ze, one

e ye at a t ime (you c an do an H in the a ir with you r fin ger )

y te sts fo r syner gist an d anta gon ist musc le funct ion

y Sherr ington s La w of Re ciprocal Inner vat ion :an inner vat ional impu lse f lows to the a ct ive musc le wh ile the inner vat ional impu lse is

inh ibite d to the musc le s anta gon ist

2 . Ver sion y simu ltane ous mov e ment of e ye s f rom a

primar y posi t ion to a se con dar y posi t ion (6car dinal posi t ions)

y te st fo r yoke musc le s (musc le s re spo n sib le for dire ct ing e ye s)

y Her ing s La w of Equ al Inner vat ion : an e qu al inner vat ional impu lse f lows to ea ch musc le invo lve d in the a ct ion

Both te sts sh ou ld b e do ne, to b e a ble to d ete ct e ven slight wea kne ss of o ne musc le of an e ye.

To re po rt fin dings:

Tonometry

y M ea su re m ent of intra ocu lar pre ssu re y It is an in dire ct m ea su re of the a qu e ous f luid

dyna mics of the e ye. y Use d in e valuat ion of gla ucom a, ocu lar

bin f la mm at ion, in jurie s to the e ye f rom tra um a

M eth ods of M ea su rin g IOP

a. Pal pat ion Tonom etr yy Ask the pat ient to look dow n, pla ce two

th umbs o n the e ye ball wh ile the re st of the finger s re st on the fo rehea d . Pre ss o ne th umb o n the e ye ball wh ile the o ther f eel s

the re bou nd . Obs er ve the pre ssu re an dsof tne ss/fi rmne ss .

y Re minder : do n ot do p al pat ion ton om etr yin susp e cte d p enetrat ing in jurie s of the e ye.

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b . Indentat ion Tonom etr yy m ea su re s the pre ssu re re qui re d to in dent

the co rnea

c. App lanat ion Tonom etr yy m ea su re s the force re qui re d to f latten or

a pp lanate an area of co rnea.

Fundoscopy

y Dire ct insp e ct ion of the ret ina, op t ic ner ve an d ch oroid

y Use of a dire ct op hthal moscop e y The dire ct exa minat ion of the ocu lar fundus

m a y a id in the dia gnosis of a pr imar y ocu lar prob le m o r give a clue to the earl y dia gnosisof a sys te mic dis ea se.

Remember, hold the ophthalmoscope in your right hand toexamine the patients right eye; hold it in your left hand toexamine the patients left eye. This keeps you from bumping the patients nose and gives you more mobility and closer range for visualizing the fundus.

Obs er ve for the fo llowi ng y ROR (re d-o ran ge re f lex )

- the re f le ct ion of the ret ina on the len s- normal : re d-o ran ge; a bnormal : wh ite pupi l (in le ukoko ria )

y M e dia - re po rt in findin gs if it is clear

y Disc Border - re po rt in findin gs if it is dis t in ct or no t

y C:D Rat io

- n orm al : 0 .3 (the cup occupi e s 1/3 of the he ight of the ent ire disk)

y A:V Rat io- n orm al : 2 :3 ( the arter y is 2 /3 the size of the ve in )

y He mo rrha ge s/Exud ate s- indicate pre sen ce or a bs en ce

y Foveal Re f lex a sin gle re f le ct ion of light mus t be obs er ve d w hen you s h ine light on the fovea

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Type s of Exud ate s:a. har d ex ud ate / tr ue ex ud ate with clear bo rder; lipid an d lipid- la den m a crop ha ge s extra va sate d f rom v e ssel sb . sof t ex ud ate s- wi th f luffy bo rder; area s of i n f ar ct.

Ret inal He mo rrha ge

Summ ar yy Ocu lar h istory wa s discuss e d in cludi ng the diff erent e ye comp la int sy Expla ine d the diff erent op hthal mo logic exa minat ion s, an d its sign ifican ce y De scribe d the te chn iqu e in doi ng the diff erent op hthal mo logic exa minat ion sy Discuss e d normal a s well a s a bn orm al fin dings

Trus t in the Lord wi th all you r heart an d lean no t in you r ow n un der stan ding , in all you r wa ys a cknow le dge Him , an d He will ma ke you r path s s tra ight.

- Prover bs 3:5-6

HAPPYHAPPY2 1ST BIRTH DAYTO AIRA DELOS SANTOS!! (woo h oo !! )

^^ Augus t 9, 20 11