The Chief Complaint [CC] History of Present Illness [HPI] Past Medical History [PMH].. Past Medical History [PMH]
|
|
|
- Archibald Harvey
- 5 years ago
- Views:
Transcription
1 Ocular Manifestations of Systemic Diseases Komal B. Desai, MD Assistant Professor Eye Foundation of Kansas City Vision Research Center UMKC, School of Medicine Sabates Eye Centers Overview: History Taking The ability to take a thorough and meaningful history requires knowledge of the basic methods and also the correlations between specific medical conditions and their associated signs and symptoms. Discuss basic components: CC/HPI PMHx/PSHx FHx ALL/MEDS/SOC ROS The Chief Complaint [CC] What is the reason for today s visit? Maybe be 1 or more complaints Duration of each? Use patients own words if possible Try to incorporate medical language History of Present Illness [HPI] Tell me about your problem If you say, what s the matter with you Patient says, that s what I came to find out Focus your questions Let the patient s story guide related questions Ex: blurry vision do you use glasses? is it blurry at near/distance? double vision? Past Medical History [PMH] Past Medical History [PMH].. Should include past ocular history Eye surgeries; lasers Glaucoma Cataracts Lazy eye Diabetic eye disease Macular degeneration Traumatic eye injury Retinal detachment Diabetes mellitus Thyroid disease Hypertension Asthma Cardiovascular disease Stroke (TIA or CVA) Hypercholesterolemia Migraines Arthritis Osteo Rheumatoid Degenerative Sarcoidosis Tuberculosis
![Family History [FHx] Do any diseases run in the family? Always ask about: Diabetes, Hypertension, Heart Disease Glaucoma, Cataracts Unusual Blindness Cancer Allergies Are you allergic to any medicine?](/docs-images/81/83493280/images/2-0.jpg "List the type of allergy Are you allergic to shellfish or have you had any problems with contrast dye (as in CT scans)? Correlation with fluorescein dye (FA) Vasovagal reaction at dentists/needles?")
2 Family History [FHx] Do any diseases run in the family? Always ask about: Diabetes, Hypertension, Heart Disease Glaucoma, Cataracts Unusual Blindness Cancer Allergies Are you allergic to any medicine? List the type of allergy Are you allergic to shellfish or have you had any problems with contrast dye (as in CT scans)? Correlation with fluorescein dye (FA) Vasovagal reaction at dentists/needles? Medications Review of Systems [ROS] Eyedrops Including visine, tears Systemic Medications Vitamins Herbal supplements Main purpose: Make sure that you have not missed any important symptoms that could be relevant For instance. Positive ROS with rash and shortness of breath may correlate with uveitis findings on exam and guide the Doctor to test for sarcoidosis Positive ROS with headache, dizziness may correlate with retinal findings of optic nerve edema and retinal hemorrhages hypertensive retinopathy/ptc A general question that introduces each system is helpful More specific questions should be guided by PMHx, complaints, age, and general state of health Examples: How are your ears and hearing? How about your lungs and breathing? Any trouble with your heart? How is your digestion and bowels? The ROS is not a list of medical conditions the patient has. You should not list HTN, DM, High Chol in this section!!! ROS.. General-weakness, fatigue, fever, weight change Skin- rashes; color changes; brittle; dry Lymph Nodes- enlarged; painful Musculoskeletal- pain; arthralgia; weakness Endocrine- polyphagia; polydipsia; goiter Head- headache; migraine; trauma; syncope ROS.. Eyes- as previously mentioned Ears- deafness; tinnitus; vertigo; pain Nose- rhinitis; sinus symptoms; epistaxis Throat- hoarse; sore; vocal changes Respiratory-SOB; cough; pleurisy CV- chest pain; tachycardia; palpitations; claudication
3 ROS. GI- dysphagia, nausea, vomiting, pain, hematemesis GU- polyuria, hematuria, pain, pregnant? CNS- paralysis, paresthesias, sweating, intolerance to hot or cold Psych- mood, hallucinations, sleep disturbances, depression ROS.The Desai Shortcut --- have you had any Nausea Vomiting Diarrhea Fever Chills Headache dizziness Wt loss Wt gain Chest pain SOB ***TAKES ABOUT 30 SECONDS*** Blood in urine Blood in stool Coughing up blood Stomach pain Rashes Muscle aches Joint aches Swelling in arms/legs Problems chewing Problems swallowing Problems sleeping Categories of Systemic Disease Congenital Traumatic Vascular Neoplastic Autoimmune Idiopathic Infectious Metabolic/Endocrine Drugs/Toxins Congenital Disorders Down syndrome Marfan syndrome Myotonic dystrophy Neurofibromatosis ** Congenital lysosomal storage disorders One of the most common inherited disorders (3 in 10,000) Characterized by: 6+ café-au-lait spots 2+ cutaneous neurofibromas Lisch nodules (95%) Intertriginous freckles Sphenoid dysplasia Optic nerve glioma Positive Family History -Neurofibromatosis
4 Traumatic Disorders Vascular Disorders Shaken baby syndrome Child abuse Dilated fundus Preretinal heme Intraretinal heme Vitreous heme Legal implications Hypertension Embolic disease Amaurosis fugax Vascular occlusions Migraines Blood dyscrasias -Hypertension -Intracranial Hypertension Hypertensive retinopathy Vessel attenuation & arteriosclerosis Flame-shaped hemorrhages Cotton-wool spots Precapillary occlusion of arterioles Ischemic infarction of superficial retina Papilledema Papilledema Increased ICP w/ optic nerve edema Symptoms Visual obscurations Loss of color vision Visual field defects Causes Pseudotumor cerebri Infection/inflammation Neoplasm Thrombosis Hematoma Hydrocephalus ** PINT of H2O ** -Embolic Disease -Amaurosis Fugax Severe vision loss Transient Permanent Location Ophthalmic artery Central retinal artery Sources Cholesterol: Carotids Calcium: Cardiac Talc: IVDA Lipid/air: chest trauma Monocular dimming of vision Returns to normal once emboli passes Sudden, transient, painless loss of vision curtain coming down over eye Temporary arterial obstruction TIA of ophthalmic/ central retinal artery Lasts few minutes Eval: Cardiovascular, CNS, Ophthalmic
5 -Central Retinal Artery Occlusion Severe vision loss Painless Retina is yellow-white Swollen due to lack of blood supply Cherry red spot in macula Rebreathing carbon dioxide Topical beta blockers IV acetazolamide 500 mg Digital massage of globe Anterior chamber paracentesis Calcium channel blockers Hyperbaric oxygen Interventional radiology -CRAO Treatments -Central Retinal Vein Occlusion -Migraines Painless vision loss Mild to profound Macular edema Rapid onset Examination Diffuse retinal hemorrhages Cotton-wool spots 50% have assoc. POAG or HTN System evaluation HTN, elevated lipids Coagulopathies, collagen vascular diseases Paraneoplastic syndromes Visual symptoms Scintillations Amaurosis fugax Transient homonymous hemifield loss Transient cortical blindness Types: classic, common, complicated, ocular Treatment Evaluate visual loss and possible CNS vascular disease Prophylactic treatment Stop oral contraceptives? -Blood Dyscrasias -Blood Dyscrasias Hyperviscosity syndromes PCV, MM, dysproteinemia, leukemia Amaurosis fugax; permanent visual loss Retinal heme, disc edema, retinal edema Recommendations Periodic eye exams if asymptomatic Prompt referral for any ocular symptoms Sickle Cell Retinopathy HbSC disease is most common Retinal occlusions in periphery Ischemia: sea fan neovascularization Asymptomatic with severe disease
6 Neoplastic Disorders Autoimmune Disorders Common neoplasms Primary ocular melanoma CNS lymphoma Metastatic carcinoma Most common in adults Breast, lung F Lung, prostate M Treatment XRT Chemotherapy Eye (resection/enucleation) Eye exams at regular intervals Connective tissue diseases Dry eyes most common manifestation Burning, foreign body sensation, photophobia Treatment: artificial tears, night time lubrication, punctal occlusion Sjogren s syndrome Dry eyes (keratoconjunctivitis sicca) Rheumatoid arthritis Dry eyes, episcleritis, scleritis, corneal ulcers uveitis -Connective tissue diseases -Giant Cell Arteritis Temporal arteritis Systemic vasculitis in people over 60 Symptoms Headache Scalp tenderness* Jaw claudication* Polymyalgia rheumatica Acute visual loss (ischemic optic neuropathy) Diagnosis History, stat ESR, fundus exam, temporal artery biopsy Treatment High-dose corticosteroid therapy Start immediately if high degree of suspicion exists -Thyroid Ophthalmopathy Graves disease Doesn t always correlate with serum thyroid levels Can progress after thyroid function is normalized Treatment: lids, muscle, orbital decompression -Myasthenia Gravis Autoimmune disease affecting Ach Receptors Conduction deficit at neuromuscular jxn 75% present with ocular manifestations Bilateral ptosis Limitation of motility, diplopia 20% will not have systemic MG Eval in all patients with ptosis/diplopia of unclear etiology (especially if worsens with fatigue)
7 Idiopathic Disorders Sarcoidosis 25% have ocular involvement Granulomatous uveitis steroids Multiple Sclerosis Optic neuritis Optic nerve edema Acute, painful vision loss May be initial sign IV steroids MRI, neurology eval Infectious: AIDS Ocular manifestations Dry eye Cotton wool spots CMV retinitis IV therapy is treatment of choice Ganciclovir Foscarnet Kaposi s sarcoma of lids/conjunctiva CD4 counts <100 cell/ml for infectious diseases (CMV) Metabolic/Endocrine: DM Diabetic retinopathy is leading cause of new blindness is year olds in the United States Classification: No retinopathy -1yr Background (non-proliferative) -6mos Hemorrhages Cotton wool spots Proliferative -3mos Neovascularization of disc/ retina Macular edema Drugs/Toxins Systemic medications cause significant ocular side effects Toxic retinopathy Thioridazine Chloroquine Hyroxychloroquine Tamoxifen Toxic optic neuropathy Ethambutol Isoniazid Fluoroquinolone Require monitoring with fundus exams at regular intervals Conclusions Ophthalmologist Primary Care Physician
Neuro-Ocular Grand Rounds Anthony B. Litwak,OD, FAAO VA Medical Center Baltimore, Maryland
Neuro-Ocular Grand Rounds Anthony B. Litwak,OD, FAAO VA Medical Center Baltimore, Maryland Dr. Litwak is on the speaker and advisory boards for Alcon and Zeiss Meditek COMMON OPTIC NEUROPATHIES THAT CAN
Neuro-Ocular Grand Rounds
Neuro-Ocular Grand Rounds Anthony B. Litwak,OD, FAAO VA Medical Center Baltimore, Maryland Dr. Litwak is on the speaker and advisory boards for Alcon and Zeiss Meditek COMMON OPTIC NEUROPATHIES THAT CAN
Professor Helen Danesh-Meyer. Eye Institute Auckland
Professor Helen Danesh-Meyer Eye Institute Auckland Bitten by Ophthalmology Emergencies Helen Danesh-Meyer, MBChB, MD, FRANZCO Sir William and Lady Stevenson Professor of Ophthalmology Head of Glaucoma
LECOM Health Ophthalmology
Patient Name: Date of Birth: New Patient Questionnaire Your answers will be used by your healthcare provider get an accurate history of your medical conditions and ocular concerns. If you are uncomfortable
Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1
Appointment Date: Page 1 Chief Complaint: (Please write reason, symptoms, condition or diagnosis that prompts your appointment) Past Medical History PERSONAL SKIN HISTORY YES NO Yes - Details Melanoma
Case Follow Up. Sepi Jooniani PGY-1
Case Follow Up Sepi Jooniani PGY-1 Triage 54 year old M Pt presents to prelim states noticed today he had reddness to eyes, states worse in R eye. Pt denies any pain or itching. No further complaints.
PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only)
PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only) 1. What is the main problem that you are having? (If additional space is required, please use the back of this
Objectives. Unexplained Vision Loss: Where Do I Go From Here. History. History. Drug Induced Vision Loss
Objectives Unexplained Vision Loss: Where Do I Go From Here Denise Goodwin, OD, FAAO Coordinator, Neuro-ophthalmic Disease Clinic Pacific University College of Optometry goodwin@pacificu.edu Know the importance
PATIENT HEALTH QUESTIONNAIRE Radiation Oncology
REVIEWED DATE / INITIALS Safety: Yes No Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? Allergies: Yes No If YES, please list medication allergies:
PATIENT HEALTH QUESTIONNAIRE Radiation Oncology
REVIEWED DATE / INITIALS Safety: Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? Allergies: If YES, please list medication allergies: Do you have
Headache Follow-up Visit Form
!1 Headache Follow-up Visit Form We will be unable to see you unless this form is completely filled out. We appreciate your thoroughness. Name DOB Age Today s Date Referring doctor: Primary doctor: Neurologist:
NORTHERN VIRGINIA PULMONARY AND CRITICAL CARE ASSOCIATES, P.C.
NORTHERN VIRGINIA PULMONARY AND CRITICAL CARE ASSOCIATES, P.C. Past Medical History AIDS/HIV disease Anemia Asthma Bronchitis Cancer Date of last Chest X-ray Diabetes Mellitus, Type I Diabetes Mellitus,
LECTURE # 7 EYECARE REVIEW: PART III
LECTURE # 7 EYECARE REVIEW: PART III HOW TO TRIAGE EYE EMERGENCIES STEVE BUTZON, O.D. EYECARE REVIEW: HOW TO TRIAGE EYE EMERGENCIES FOR PRIMARY CARE PHYSICIANS Steve Butzon, O.D. Member Director IDOC President
Patient with Daily Headache NTERNATIONAL CLASSIFICATION HEADACHE DISORDERS. R. Allan Purdy, MD, FRCPC,FACP. Professor of Medicine (Neurology)
Patient with Daily Headache NTERNATIONAL CLASSIFICATION of R. Allan Purdy, MD, FRCPC,FACP HEADACHE DISORDERS Professor of Medicine (Neurology) 2nd edition (ICHD-II) Learning Issues Headaches in the elderly
TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM
TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM PATIENT NAME: DATE OF BIRTH: TVA Physician being seen: Date of Visit: PAST MEDICAL HISTORY HEART PROBLEMS NEUROLOGICAL Congestive Heart Failure
DATE OF BIRTH: MELANOMA INTAKE
MELANOMA INTAKE GENERAL INFORMATION How was your first diagnosed? (Check the diagnosis that describes your condition.) Melanoma Merkel Cell Carcinoma Squamous Cell Carcinoma Basal Cell Carcinoma Other
NANOS Patient Brochure
NANOS Patient Brochure Transient Visual Loss Copyright 2016. North American Neuro-Ophthalmology Society. All rights reserved. These brochures are produced and made available as is without warranty and
PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM B S M R W A G KS MAC Z GR SO ZA L Please tell us about yourself so we can help you make the best decisions about your care. Date: Social Security #: E-mail: Name: MR / MRS / MS
EYE TRAUMA: INCIDENCE
Introduction EYE TRAUMA: INCIDENCE 2.5 million eye injuries per year in U.S. 40,000 60,000 of eye injuries lead to visual loss Introduction Final visual outcome of many ocular emergencies depends on prompt,
Amarillo Surgical Group Doctor: Date:
Office Visit Information (General Surgery) Amarillo Surgical Group Doctor: Date: Patient s Information Name: Last First Middle Social Security #: Date of Birth: Age Gender: [ Male / Female ] Marital Status:
9/11/11. Temporal Arteritis. Background. Background. Richard E. Castillo, OD, DO NORTHEASTERN STATE UNIVERSITY Director, Ophthalmic Surgery Service
Temporal Arteritis Richard E. Castillo, OD, DO NORTHEASTERN STATE UNIVERSITY Director, Ophthalmic Surgery Service 1 Background Giant Cell Arteritis Temporal Arteritis Cranial Arteritis Granulomatous Arteritis
PLEASE COMPLETE ALL SECTIONS OF THIS FORM
PLEASE COMPLETE ALL SECTIONS OF THIS FORM Patient Name: Date of Birth: Referring Doctor? (Name, telephone number and address) Chief Complaint: Why have you come here? How did it start? What are the symptoms?
Patient Intake Form for Allegany Ear, Nose, & Throat
Patient Intake Form for Allegany Ear, se, & Throat Patient Name: What brings you to the office today? Who is your primary care doctor? Please list your current medications: Are you allergic to any medications?
Mild NPDR. Moderate NPDR. Severe NPDR
Diabetic retinopathy Diabetic retinopathy is the most common cause of blindness in adults aged 35-65 years-old. Hyperglycaemia is thought to cause increased retinal blood flow and abnormal metabolism in
CONSULTATION ADMITTANCE FORM
CONSULTATION ADMITTANCE FORM Last Name: First Name: Address: City Postal Code: Home Phone: Work Phone: Age: Birth date (dd/mm/yr): Sex: M / F Height Weight Occupation: Alberta Health Care #: PLEASE CHECK
5/2/2016 EYE EMERGENCIES. Nathaniel Pelsor, O.D., FAAO Talley Medical-Surgical Eye Care Associates. Anatomy. Tools
EYE EMERGENCIES Nathaniel Pelsor, O.D., FAAO Talley Medical-Surgical Eye Care Associates Anatomy Tools 1 Contact dermatitis Blepharitis HSV Preseptal Cellulitis Anterior Chamber Subconjunctival hemorrhage
Medical History Form
Medical History Form NAME DOB / / TODAY S DATE MEDICAL HISTORY What medical Conditions do you have? Select all that apply, or write in if not listed: Diabetes High Blood Pressure Thyroid Disorder Heart
PATIENT INFORMATION FORM
PATIENT INFORMATION FORM Name: (First) (Middle) (Last) Birth Date: _ Social Security Number: _ Address: _Apartment #: City: State: Zip Code: Home#: Work# Cell#:_ Marital Status: Single Married Divorced
Questionnaire for Lipedema Patients
Questionnaire for Lipedema Patients Name Date of diagnosis Date Name of physician making diagnosis Do you also have lymphedema? What areas of the body are affected? Outside of thighs Inner thighs Knees
Please list any treatments you have previously had for current illness. (Physical Therapy, Surgery, Radiation, etc.)
Date: Patient Name: D.O.B Last First M.I History of Present Illness: What is the reason for your visit? Date symptom started? Please list any treatments you have previously had for current illness. (Physical
Medical History Record
Medical History Record Today s For faster service, please complete the following form prior to arriving at our office. FIRST NAME: M.I. LAST NAME: Address City State Zip Code D.O.B. Sex: M F Email Home
Alan G. Kabat, OD, FAAO (901)
THE SWOLLEN OPTIC DISC: EMERGENCY OR ANOMALY? Alan G. Kabat, OD, FAAO (901) 252-3691 Memphis, Tennessee alan.kabat@alankabat.com Course description: The swollen disc presents a diagnostic dilemma. While
/ / - - / / Age: USF Cutaneous Oncology Program. Skin Cancer Questionnaire. Patient Information: Fax completed forms to:
Page 1 of 8 Patient Information: Last Name: First Name: Initial: Address: Address (cont.) : City: State: Zip Code: Phone: - - Social Security Number: Date of Birth: - - Age: Sex: Female Male Email Address:
EDWARD M STROH MD PC RETINA New Patient Packet
EDWARD M STROH MD PC RETINA New Patient Packet PATIENT INFORMATION First Name Middle Last Birth Date / / Age Gender: MALE FEMALE Street Address City State Zip Home Phone Employer Cell Phone Other Phone
Index. Note: Page numbers of article titles are in boldface type.
Index Note: Page numbers of article titles are in boldface type. A Acetazolamide, in idiopathic intracranial hypertension, 49 52, 60 Angiography, computed tomography, in cranial nerve palsy, 103 107 digital
Laser Vein Center Thomas Wright MD Page 1 of 4
Demographics Laser Vein Center Thomas Wright MD Page 1 of 4 Patient Name: Address: City, St, Zip Primary Phone: Alternate: DOB: Social Security #: Insurance Information Primary Insurance ID# Group# Subscriber
New Patient History. Name: DOB: Sex: Date: If yes, give the name of the physician who did your evaluation or ordered your tests:
New Patient History Name: DOB: Sex: Date: Chief Complaint: 1. Give a brief description of the problem you are seeking treatment for today: 2. Have you been evaluated for this problem or had any tests for
Past Medical History. Chief Complaint: Appointment Date: Page 1
Appointment Page 1 Chief Complaint: (reason, symptoms, condition or diagnosis that prompts your appointment) Past Medical History EYES Yes No Yes Details Glaucoma EAR, NOSE AND THROAT Hearing difficulty
Dear Mercy Cancer Center Radiation Oncology Patient
Dear Mercy Cancer Center Radiation Oncology Patient Welcome to our Department. In order to complete our records, and enable our physicians to ensure that your questions are fully addressed, we appreciate
Inner Balance Acupuncture
Patient Information Inner Balance Acupuncture 274 Southland Drive, Suite 101, Lexington, KY 40503 859-595-2164 www.acupunctureky.com Name: Today s date: Age: Male Female Marital status: Date of Birth:
Learning Objectives. Introduction. Reading List. Significance. Introduction 10/16/2008
Learning Objectives Systemic Diseases with Ocular Manifestations Dr Nathan Kerr 1. To describe the ocular symptoms and signs associated with common systemic diseases 2. To be familiar with the non-ophthalmic
Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?
![Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?](/thumbs/87/97078208.jpg "Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?")
ENDOCRINOLOGY HEALTH HISTORY What is the reason for your visit? MEDICATIONS List current prescription and over-the-counter medications. Also list current vitamin, herbal, and nutritional supplements: MEDICATION/SUPPLEMENT
NEW PATIENT INFORMATION FORM
NEW PATIENT INFORMATION FORM Name: LAST FIRST MIDDLE Date of Birth: Sex: Marital Status: SS Number: Address: City: State: Zip Phone: Home Cell Work Email: Communication Preference: Patient Portal Phone
HISTORY INTAKE FORM **CIRCLE ALL THAT APPLY ABOUT YOU**
Name: Date: D.O.B: HISTORY INTAKE FORM **CIRCLE ALL THAT APPLY ABOUT YOU** PAST MEDICAL HISTORY: Anxiety Arthritis Asthma A-Fib BPH Bone Marrow Transplant Breast Cancer Colon Cancer COPD Coronary Artery
J. Van Lier Ribbink, M.D., F.A.C.S. Center for Endocrine and Pancreas Surgery at Honor Health
J. Van Lier Ribbink, M.D., F.A.C.S. Center for Endocrine and Pancreas Surgery at Honor Health Patient Clinical Information Questionnaire 1.0 Date of Questionnaire Completion; / / 2.0 Patient Data 2.1 Name:
Pearls, Pitfalls and Advances in Neuro-Ophthalmology
Pearls, Pitfalls and Advances in Neuro-Ophthalmology Nancy J. Newman, MD Emory University Atlanta, GA Consultant for Gensight Biologics, Santhera Data Safety Monitoring Board for Quark AION Study Medical-legal
PLAS/RECON SURGERY PATIENT HEALTH HISTORY
PLAS/RECON SURGERY PATIENT HEALTH HISTORY Chief Complaint - Please describe the problem that brings you into the office today: Allergies 1. Do you have any allergies? if so, please list To Medications?
The following is a list of medications which are known to have high risk of ocular side effects
Medications have an established profile of side effects, but ocular side effects are often unrecognized, overlooked or misdiagnosed. While the ophthalmologic literature usually highlights such discoveries,
GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT
GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT Full name: Date: Telephone Number: Age: Address: Email address: CHIEF COMPLAINTS(List the problems about which you came to see the doctor) 1) 2) 3)
Faculty Financial Disclosure. Learning Objectives: Office Ophthalmology. Basic Eye Exam: What s in your pocket/office? Office Ophthalmology
Faculty Financial Disclosure Office Ophthalmology Lynn K. Gordon, MD, PhD, has no financial relationships to disclose. Lynn K. Gordon, MD, PhD Professor and Vernon O Underwood Family Chair Department of
Headache Assessment In Primary Eye Care
Headache Assessment In Primary Eye Care Spencer Johnson, O.D., F.A.A.O. Northeastern State University Oklahoma College of Optometry johns137@nsuok.edu Course Objectives Review headache classification Understand
Florida Hospital Spine Center Patient Intake Form
Florida Hospital Spine Center Patient Intake Form Today s Date Last Name First Name Middle Street Address DOB (Address, City, State, Zip Code) First Contact # Please Circle: Home Cell Other Second Contact
Bridges Family Wellness PC. New Patient Intake. Bridges Family Wellness Intake Form SE Lake Rd, Suite 102 Milwaukie, OR
New Patient Intake Bridges Family Wellness Intake Form Full Name: * What is your birthdate? MM/DD/YYYY * What is your gender identity? * Home address: * Cell Phone * Other Phone number(s): Emergency Contact
OPHTHALMOLOGY REFERRAL GUIDE FOR GPS
OPHTHALMOLOGY REFERRAL GUIDE FOR GPS A guidebook to support general practitioners in the management and referral of a range of common eye problems. Contents 3 Introduction 4 Ophthalmic Workup 6 Acute Visual
A Case of Carotid-Cavernous Fistula
A Case of Carotid-Cavernous Fistula By : Mohamed Elkhawaga 2 nd Year Resident of Ophthalmology Alexandria University A 19 year old male patient came to our outpatient clinic, complaining of : -Severe conjunctival
Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History
Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History Please take a few minutes and complete the following questions before you see the doctors so that we may learn a bit more
Review of Systems NAME: DATE OF BIRTH: DATE COMPLETED: Dear Patient,
LOS ANGELES CANCER NETWORK NEW PATIENT HEALTH QUESTIONNAIRE NAME: DATE OF BIRTH: DATE COMPLETED: Dear Patient, In order to offer optimal care for you, we need to understand your complete health status
Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left HISTORY OF PRESENT ILLNESS
CAPS PAINCARE Page 1 of 5 Today s : / / SSN (last 4 digits): xxx-xx - Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left Type of Accident/Injury: Auto Work Personal Injury
OCULAR MANIFESTATIONS OF SYSTEMIC DISEASES THUCANH MULTERER, MD
OCULAR MANIFESTATIONS OF SYSTEMIC DISEASES THUCANH MULTERER, MD UNDERGRADUATE: Philadelphia College of Pharmacy and Science 1996 MEDICAL SCHOOL: MCP Hahnemann School of Medicine, Philadelphia PA 2000 RESIDENCY:
ACTIVE EDGE CHIROPRACTIC
ACTIVE EDGE CHIROPRACTIC HEALTH HISTORY QUESTIONNAIRE PERSONAL INFORMATION Name: Female Male Alberta Health Care# Address: City: Province: Postal Code: Telephone: Home: Work: Cell: Email: Occupation: Birth
8/30/2018. Eye Disorders. Patrick Sarte. Anatomy of the Eye Uveitis Scleritis vs. Episcleritis Glaucoma Retinal Findings Eyelids
Eye Disorders Patrick Sarte Anatomy of the Eye Uveitis Scleritis vs. Episcleritis Glaucoma Retinal Findings Eyelids 1 Anatomy of the Eye Anatomy of the Eye 2 Anatomy of the Eye 3 4 A 26 year old woman
T- Timing- concise vs. complete and thorough, depending on need of presenter and audience. E- Elicit- ask for feedback- more information needed? Less?
Review of STAGE presentation framework (from umass.macy.edu, revised Alicia Monroe, MD from 2005 STFM) S- style organization, sequencing adequate to build a case for your diagnosis or a story T- Timing-
Grand Rounds. Eddie Apenbrinck M.D. University of Louisville School of Medicine Department of Ophthalmology & Visual Sciences 6/20/2014
Grand Rounds Eddie Apenbrinck M.D. University of Louisville School of Medicine Department of Ophthalmology & Visual Sciences 6/20/2014 Subjective CC: sudden painless loss of vision OD HPI: 75 year old
Patient History Form
Acct #: Patient History Form Please answer ALL questions by filling out the appropriate box(es). Name: Gender: M F Primary Care Provider: DOB: Today s Date: Referring Provider (if different from PCP):
CECILIA P MARGRET MD PhD MPH Child, Adolescent and Adult Psychiatry NE 24th ST Suite 104, Bellevue WA 98007, Phone / Fax: +1 (425)
IDENTIFYING INFORMATION PATIENT INFORMATION FORM Patient's Name: DOB: Ethnicity/race: Gender: Primary language if other than English: Address: Phone: Home/ Mobile/ Work Email: Occupation: Marital Status:
725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA (770) (770) (facsimile)
Charles Nash, III, M.D., F.A.C.P. Richard J. LoCicero, M.D. Anup K. Lahiry, M.D. Timothy M. Carey, M.D. Andrew Johnson, M.D. 725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA 30501 (770) 297-5700 (770)
RHEUMATOLOGY PATIENT HISTORY FORM
!! RAMOS RHEUMATOLOGY, PC RHEUMATOLOGY PATIENT HISTORY FORM Date: / / NAME: Birthdate: / / Last First M. I. Age: Sex: F M Marital status: Never married Married Divorced Separated Widowed Partnered/significant
VASCULAR SURGERY PATIENT HEALTH HISTORY
VASCULAR SURGERY PATIENT HEALTH HISTORY Chief Complaint - Please describe the problem that brings you into the office today: Allergies 1. Do you have any allergies? if so, please list To Medications? To
Welcome to About Women by Women
Welcome to About Women by Women Today s Date New Patient Questionnaire Name: Birth Date: / / Home Phone: Address: Cell Phone: Work Phone: Occupation: Employer: Marital Status: Married Living w/ Partner
Patient Information Last Name: First Name: Middle Initial: Address: City: State: Zip Code:
Patient Information Last Name: First Name: Middle Initial: Address: City: State: Zip Code: Date of Birth (MM/DD/YY): Social Security #: Sex: Male Female Home Phone #: Mobile Phone #: Email Address: Marital
NEW PATIENT HEALTH HISTORY
NEW PATIENT HEALTH HISTORY Patient Name Today s Date Age Birth Date Date of last physical examination What is your reason for initial visit? Pharmacy Name & Telephone # NOTE: If you have prior records
Sudden Vision Loss. Brendan Girschek, MD, FRCSC, FACS Vitreoretinal Surgery Cedar Valley Medical Specialists
Sudden Vision Loss Brendan Girschek, MD, FRCSC, FACS Vitreoretinal Surgery Cedar Valley Medical Specialists My Credentials -Residency in Ophthalmology at the LSU Eye Center in New Orleans, LA -Fellowship
New Patient Form. Patient Demographics. Emergency Information. Employment Information. Page 1 of 7. Family Health Chiropractic Care
Page 1 of 7 Patient Demographics First Name* Last Name* Date Of Birth* Home Phone* Mobile Phone Phone Gender* Email Preferred Communication Street Address 1* Street Addresss 2 Zip* City* State* Emergency
DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)
Medical History: Patient: DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N) List the names of prescription
Ocular Lecture. Sue Bednar NP Ali Atwater PA-C
Ocular Lecture Sue Bednar NP Ali Atwater PA-C Triaging Ocular Complaints Painful Eye/Red eye +/-blurry vision +/-visual loss +/-floaters +/-fevers If any of the above findings exist, pt is likely to have
Scottsdale Family Health
Please list pharmacy you would like us to use for your medications. Pharmacy Phone Number Fax Number Since your last visit: 1. Have you been diagnosed with any new medical conditions? Yes No If Yes (give
Who is filling out this intake form? Self Spouse Parent Guardian
Office Use Only: Reviewed with Patient Data Entry Scan & File Date: Date: Date: Initials: Initials: Initials: Today s Date: Who is filling out this intake form? Self Spouse Parent Guardian If you are not
OCCLUSIVE VASCULAR DISORDERS OF THE RETINA
OCCLUSIVE VASCULAR DISORDERS OF THE RETINA Learning outcomes By the end of this lecture the students would be able to Classify occlusive vascular disorders (OVD) of the retina. Correlate the clinical features
PLEASE LET US KNOW YOUR REASON FOR TODAY S VISIT : CURRENT MEDICATIONS (WITH DOSAGE) PLEASE INCLUDE VITAMINS AND HERBAL MEDICATIONS:
1 NAME: DATE OF BIRTH PLEASE LET US KNOW YOUR REASON FOR TODAY S VISIT : CURRENT MEDICATIONS (WITH DOSAGE) PLEASE INCLUDE VITAMINS AND HERBAL MEDICATIONS: PAST MEDICAL HISTORY (YOUR MEDICAL HISTORY) :
Ophthalmology. Juliette Stenz, MD
Ophthalmology Juliette Stenz, MD Required Slide Disclosures NO SIGNIFICANT FINANCIAL, GENERAL, OR OBLIGATION INTERESTS TO REPORT Required Slide At the end of this session, students will be able to: 1.
Medication Allergies
**PLEASE CHECK IN 15 MINUTES PRIOR TO APPOINTMENT WITH FORMS COMPLETED** Primary Provider at Ocotillo Internal Medicine Other Physicians you see: Jonathan Hackenyos, D.O. 1. Cheryl Maurice, M.D. 2. 3.
Caspian Acupuncture -- Health History Form Anita Tayyebi EAMP, LAc. 652 SW 150 th St Burien WA 98166
Frist Name Last: Date Phone (H) (C) (W) E-mail Address City State Zip Age DOB Place of Birth _ Marital/Partnership Status Preferred Gender Pronoun _ Profession Family Physician Telephone # Referred By
PATIENT REGISTRATION
P Account# PATIENT REGISTRATION Please answer all questions completely. PAYMENT IS EXPECTED WHEN SERVICES ARE RENDERED Date New Update Name Date of Birth Male Last First Middle Female Home Address City/State/Zip
Syncope and Seizure Questionnaire
Syncope and Seizure Questionnaire World College of Neurology 2/79 Wheatley Drive Bull Creek WA 6149 T 08 93320488 F 08 93329988 Copyright 2011. All rights reserved. Patient Name: MAIN PROBLEM I am here
Rapid Visual Loss. Dr Michael Johnson PhD FCOptom DipOrth DipGlauc DipTp(IP) Independent Prescribing Optometrist
Rapid Visual Loss Dr Michael Johnson PhD FCOptom DipOrth DipGlauc DipTp(IP) Independent Prescribing Optometrist Outline Pathophysiology Differential diagnosis. Patient scenarios in community practice:
PATIENT INFORMATION SHEET
ALAMO NEUROSURGICAL INSTITUTE 414 W SUNSET, SUITE 205 SAN ANTONIO, TEXAS 78209 WWW.ANI-ONLINE.COM OFF: 210.564.8300 FAX: 210.564.8399 PATIENT INFORMATION SHEET Patient Name (Last, First, Mi): SSN: Street
DNA CENTER New Patient Information
DNA CENTER New Patient Information Name Email: Address City State Zip Home Phone Work Cell Phone Social Security Number Date of birth Gender ( Male/Female) Age Please Circle: Hispanic/Latin or Non Hispanic/Latin
Course # Flashes and Floaters and Curtains, Oh My!
Course # 132 Flashes and Floaters and Curtains, Oh My! FLASHES and FLOATERS and CURTAINS, OH MY!!! FLASHES OF LIGHT Vitreous is the villain Retinal traction Retinal hole Retinal tear Migraine Classic migraine
Course # Flashes and Floaters and Curtains, Oh My!
Course # 132 Flashes and Floaters and Curtains, Oh My! FLASHES and FLOATERS and CURTAINS, OH MY!!! FLASHES OF LIGHT Vitreous is the villain Retinal traction Retinal hole Retinal tear Migraine Classic migraine
PULMONARY CARE OF CENTRAL FLORIDA, P.A. Date: / /
PULMONARY CARE OF CENTRAL FLORIDA, P.A. Date: / / Patient Name Age DOB: / / Family Physician Referring Physician Telephone Number Telephone Number Pharmacy: Phone: Fax: MEDICAL HISTORY 1. What is your
Patient History Form
Patient History Form Advanced Directive Care Plan? Yes No Name: Birth date: / / Address: Age: Sex: F M STREET DAY YEAR Telephone: Home ( ) CITY STATE DAY YEAR MARITAL STATUS: Divorced Separated Alive/Age
New Patient Packet. Patient Name: DOB: Age: Address: City: State: Zip: Address: City: State: Zip: Name: Address: Phone: Fax:
New Patient Packet Patient Name: DOB: Age: Sex: Male / Female Height: Weight: PHYSICIAN CARE Primary Care Physician: Address: City: State: Zip: Phone: Fax: Referring Physician (if different from PCP):
*542686* How severe is the problem? mild moderate severe Is it getting better or worse? Better Worse Same over the last hours days weeks months
*542686* Referring Doctor Name: Specialty: City: State: Primary Doctor Name: Specialty: City: State: Instructions: On the body drawing below, please show where you feel pain at this time. Please mark only
NEPTUNE RED BANK BRICK
NEPTUNE RED BANK BRICK Diabetes & The Eye Diabetics are more likely to develop Cataracts at a younger age. Diabetics are twice as likely to develop Glaucoma when compared to non-diabetics. The primary
Ebele C. Chira, MD 1055 Clarksville Street, Suite 190, Paris, TX Phone (903) Fax (903)
Ebele C. Chira, MD 1055 Clarksville Street, Suite 190, Paris, TX 75460 Phone (903) 905-4609 Fax (903) 905-4611 Enclosed are forms for you to complete prior to your appointment. Please bring these completed
Camas Acupuncture & Nutrition Stephanie Meinhold, LAc 405 NE 6 th Avenue Camas, WA P F
Patient Information Camas Acupuncture & Nutrition General Information Name: Date: Address: City: State: Zip Code: Phone (H): (W): Cell: Email: Appt reminders via text? Y N via email? Y N Date of Birth:
City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week
Patient Name (First Middle Last) Date of Birth Social Security # Address City State Zip Home Phone Work Phone Cell Phone Other Phone Email Place of Birth Occupation Retired Yes No Gender Male Female Status
IMAGE OF THE MOMENT PRACTICAL NEUROLOGY
178 PRACTICAL NEUROLOGY IMAGE OF THE MOMENT Gawn G. McIlwaine*, James H. Vallance* and Christian J. Lueck *Princess Alexandra Eye Pavilion, Chalmers Street, Edinburgh UK; The Canberra Hospital, P.O. Box
Center for Advanced Wound Care New Patient Questionnaire Page 1 of 6
Center for Advanced Wound Care New Patient Questionnaire Page 1 of 6 These questions are general screening questions designed to identify areas where additional attention may be required. Please bring
Medical History Form
General: Medical History Form 1. Chief Complaint: What are the main health concerns you wish to address? 2. Current and Past Treatment: Have you received treatment for these problems? Yes No, if yes, which: