HPI
This is the patient's primary reason for seeking eye care and is often recorded in the patient's own words.
What is the Chief Complaint?
This abbreviation is commonly used in ophthalmology to document a patient's sharpness or clarity of vision.
What is VA (Visual Acuity)?
This structure is responsible for protecting the eye from debris and provides additional reaction time to protect the eye from injury.
What are the eyelashes?
Timolol, Cosopt, and Combigan are commonly prescribed to treat this eye disease by lowering intraocular pressure.
What is glaucoma?
According to the WHO 5 Moments, hand hygiene should be performed immediately after touching this, even if you never touched the patient directly.
What are patient surroundings (equipment, exam chair, slit lamp, or tonometer)?
This part of the history explores the onset, duration, severity, location, modifying factors, and associated symptoms related to the patient's chief complaint.
What is the History of Present Illness (HPI)?
This is the primary reason visual acuity is measured at every patient visit before the provider examination.
What is establishing and monitoring a patient's visual function over time?
The most common form of glaucoma occurs when fluid does not flow freely through the trabecular meshwork, causing increased intraocular pressure and optic nerve damage.
What is Primary Open Angle Glaucoma (POAG)?
Vigamox (moxifloxacin), Polytrim, and Ofloxacin belong to this category of eye medications used to treat infections.
What are ocular antibiotics?
You check a patient's IOP with gloves on, then use the keyboard to enter findings. Before instilling dilating drops, infection control standards require this sequence of actions.
What is remove the gloves, perform hand hygiene, and put on a new pair of gloves?
This comprehensive collection of information includes the Chief Complaint, HPI, Medical History, Systemic Medications, Ocular Medications, Family History, Social History, and Review of Systems and helps the provider develop a complete picture of the patient's health.
What is the Patient History?
Corneal edema, dense cataracts, vitreous hemorrhage, and posterior capsule opacification can all decrease vision because they affect this part of the visual system.
What are the ocular media?
During an eye exam, a patient presents with pain, contact lens overwear, and a corneal infection resulting from a break in the epithelium.
What is a corneal ulcer?
Prednisolone acetate and Durezol are examples of these medications used to reduce ocular inflammation, but they can increase intraocular pressure with prolonged use.
What are steroids?
This critical disinfecting principle is violated when staff wipe equipment dry immediately instead of allowing the surface to remain wet.
What is follow the required disinfectant contact (dwell) time?
The patient uses Latanoprost nightly and has a mother with glaucoma. These two history sections can significantly influence risk assessment for ocular disease and treatment planning.
What are Ocular Medications and Family History?
Name three factors that should be verified before recording a visual acuity measurement.
What are
This retinal condition is characterized by the growth of abnormal blood vessels stimulated by VEGF due to retinal ischemia.
What is Proliferative Diabetic Retinopathy (PDR)?
Metformin, Ozempic, and insulin are used to manage this systemic disease, which is a major risk factor for diabetic retinopathy.
What is diabetes mellitus?
An opened eye-drop bottle falls onto the clinic floor during patient care. Infection prevention guidelines consider the bottle compromised and require this action.
What is discard the bottle and replace it with a new one?
A patient reports smoking one pack per day, works outdoors, denies headaches or neurological symptoms, but notes frequent dry mouth and joint pain. These findings are gathered from two sections that help identify lifestyle risk factors and systemic symptoms affecting eye disease.
What are Social History and Review of Systems (ROS)?
A patient with 20/80 vision improves to 20/30 through a pinhole. This most likely indicates this cause of decreased vision.
What is a refractive error?
This diagnostic test produces cross-sectional images of ocular tissues and is routinely used to monitor both glaucoma progression and fluid associated with wet macular degeneration.
What is Optical Coherence Tomography (OCT)?
Lisinopril, Losartan, and Amlodipine are commonly prescribed to treat this condition.
What is hypertension (high blood pressure)?
A technician recaps a used needle with two hands before disposal. This unsafe practice violates one of the most important rules in this safety category designed to prevent bloodborne pathogen exposure.
What is sharps safety?