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187 Cards in this Set
- Front
- Back
Step 1 of Interview, Histories and Write Ups
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Set the stage for the interview (30-60 sec)
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Step 2 of Interview, Histories and Write Ups
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Elicit chief concern & set agenda (1-2 min)
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Step 3 of Interview, Histories and Write Ups
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Begin the interview with non-focusing skills that help the patient to express him/herself (30-60 sec)
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Step 4 of Interview, Histories and Write Ups
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Use focusing skills to learn 3 things: Symptoms story, personal context, and emotional context (3-10 min)
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Step 5 of Interview, Histories and Write Ups
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Transition to middle of the interview (clinician-centered phase) (30-60 sec)
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Step 6 of Interview, Histories and Write Ups
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Obtain a chronological description of the HPI (History of present illness)
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Step 7 of Interview, Histories and Write Ups
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Past medical history
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Step 8 of Interview, Histories and Write Ups
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Social history
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Step 9 of Interview, Histories and Write Ups
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Family history
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Step 10 of Interview, Histories and Write Ups
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Review of systems
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Step 11 of Interview, Histories and Write Ups
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End of the Interview: diagnosis, prognosis, plan
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History of present illness (HPI)
Should include the seven attributes: |
1) Location-ie:
2) Quality- 3) Quantity or severity- 4) Timing/Onset- 5) Setting- 6) Factors aggravating or alleviating- 7) Associated manifestations- |
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REVIEW OF SYSTEMS: General
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Wgt Δ; weakness; fatigue; fevers
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ROS: Skin
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Rash; lumps; sores; itching; dryness; color change; Δ in hair/nails
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ROS: Head
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Headache; head injury; dizziness
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ROS: Eyes
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Vision Δ; corrective lenses; last eye exam; pain; redness; excessive tearing; double vision; blurred vision; scotoma
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ROS: Ears
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Hearing Δ; tinnitus; earaches; infections; discharge
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ROS: Nose/Sinuses
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Colds; congestion; discharge; itching; hay fever; nosebleeds
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ROS: Throat
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Bleeding gums; dentures; last dental exam; sore tongue; dry mouth; sore throats; hoarse
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ROS: Neck
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Lumps; swollen glands; goiter; pain; neck stiffness
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ROS: Breasts
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Lumps; pain; discomfort; nipple discharge
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ROS: Pulmonary
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Cough—productive/non-productive; hemoptysis; dyspnea; wheezing; pleuritic pains
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ROS: Cardiac
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Chest pain or discomfort; palpitations; dyspnea; orthopnea; PND; edema
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ROS: GI
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Appetite Δ; jaundice; nausea/emesis; dysphagia; heartburn; pain; belching/flatulence; Δ in bowel habits; hematochezia; melena; hemorrhoids; constipation; diarrhea; food intolerance
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ROS: Urinary
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Frequency; nocturia; urgency; dysuria; hematuria; incontinence
MALES: caliber of urinary stream; hesitancy; dribbling |
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ROS: G/U (General)
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Sexual habits; interest; function; satisfaction; use of birth control methods; HIV exposure
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ROS: Male G/U
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Discharge from or sores on penis; testicular pain/masses
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ROS: Female G/U
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Menarche; frequency/duration of menses; dysmenorrhea; PMS symptoms: bleeding between menses or after intercourse; LMP
Vaginal discharge; itching; sores; lumps Menopause; hot flashes; post-menopausal bleeding; |
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ROS: Peripheral Vascular
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Claudication; leg cramps; varicose veins; hx of blood clots
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ROS: MSK
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Muscle or joint pain; joint stiffness
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ROS: Neuro
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Syncope; seizures; weakness; paralysis; numbness/tingling; tremors; involuntary movements
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ROS: Heme
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Hx of anemia; easy bruising or bleeding; blood transfusions
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ROS: Endo
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Heat or cold intolerance; excessive sweating; polydipsia; polyphagia; polyuria; glove or shoe size
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ROS: Psych
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Nervousness/anxiety; depression; memory changes; suicide attempts
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The width of the cuff should be
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about 40% of the upper arm circumference.
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Appropriate cuff size is mandatory
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if too big will falsely read Low, and if too small will falsely read high.
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Subclavian steal (Dx from BP on both arms)
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- narrowing of the proximal subclavian artery causing retrograde flow from vertebral or carotid arteries to supply the arm with blood
- Lung cancer, or lightheadedness. |
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Blood pressure should be taken in both arms at least once. If a pressure difference of more than 10-15 mm Hg may be signs of
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Subclavian Steal syndrome or aortic dissection.
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Aortic dissection (Dx from BP on both arms)
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- Tear in the inner arterial wall of the aorta causing blood to flow between layers of the artery and tearing them apart.
- This is associated with severe chest pain radiating to the back typically. |
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Pre-hypertension
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120-139/ 80-89
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Hypertension
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Stage 1 140-159/ 90-99
Stage 2 >160/>100 |
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Hypertension Urgency
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>180/ >100
* no signs ofend organ damage |
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Hypertension Emergency
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>210/ >110
***signs of end organ damage (EOD) |
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Unequal blood pressures in Arms and legs
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could signify Coarctation of the aorta or Occlusive aortic disease
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Coarctation of the aorta
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- narrowing of the thoracic aorta resulting in lower blood pressures in the legs compared to hypertension in the arms.
* normal in children |
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Occlusive aortic disease
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- has HTN in the arms and low in the legs due to narrowing of the aorta.
- In adult male may lack hair on legs. |
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Orthostatic hypotension
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fall of SBP > 20 mm Hg
or rise in heart rate >10-20 |
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Pulsus alternans
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- abnormal pulse that alternates amplitude (intensity) from beat to beat despite the rhythm being regular.
- indicates left ventricular failure and may be accompanied by S3 beat |
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Pulsus paradoxical
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- decrease in amplitude on quiet respirations and usually increases with quiet inspiration.
- found in cardiac tamponade, constrictive pericarditis, and COPD |
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Cheyne-Stokes
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- deep breathing alternating with periods of apnea
- could signify heart failure, uremia, respiratory depression from drugs or brain damage |
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Obstructive Breathing
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- expiration phase is prolonged because of narrow airways that increases resistance.
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Kussmual
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- deep and labored ax with acidosis, DKA and renal failure
- a form of hyperventalation |
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Fever
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temperature of >100.5
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Estimate Average weight for adult
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- Male: 106 lbs for 5’ + 6 lbs for every inch above
- Female: 105 lbs for 5’ + 5 lbs for every inch above |
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Acromegaly- presentation
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- Elongated head, prominence of the boney forehead, and lower jaw.
- Soft tissue – large elongated ears, nose and lips |
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Turner Syndrome (genetic defect in females)- presentation
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- Significant edema of the hands and feet at birth may be a sign.
- Short statue, broad chest, low hair line, webbing of the neck, low set ears, lymphedema, reproductive sterility, amenorrhea |
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Down Syndrome: (trisomy 21) - presentation
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- most common chromosomal abnormality
- Congnitive dysfunction, wide flat nasal bridge, small oral cavity my result in protruding tongue, short stature, low set ears |
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Marfan syndrome - definition
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- a genetic disorder causing connective tissue abnormalities.
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Marfan syndrome - presentation
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* Unusually tall, with long limbs, and long thin fingers, weak wrists.
* Abnormalities in the heart valves and aorta are the most serious complication. |
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Hirsutism - definition
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a clinical sign of abnormal androgenic (male) pattern of hair growth in women. Typically in locations women don’t grow terminal body hair.
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Hirsutism - causes
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* increase androgenic hormones.
* Typically seen in obesity, PCOS (polycystic ovarian syndrome), Cushing syndrome and other |
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Cushing Disease - definition
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an increased adrenal cortisol production.
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Cushing Disease - presentation
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“moon facies”, red cheeks, hirsutism, buffalo hump, obesity, striae, menstrual abnormalities, hypertension, elevated glucose.
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Precocious puberty - definition
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excessive sex hormones resulting in puberty in an unusually early age (prior to age 7). Typically caused by tumors, trauma, and some infections.
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Anorexia Nervosa - S/S
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Dry skin, dental caries, anemia, osteoporosis, hypotension, amenorrhea, BMI <17.5, muscle wasting
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PE: Common Complaint of the Eyes
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1) visual disturbance
2) spots (scotomas) 3) flashing light 4) corrective lenses 5) Px, redness, excessive tearing, 6) diplopia 7) symmetry, pitosis, EOM, acuity |
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PE: Common complaints of the Head
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1) headache
2) injury 3) symmetry 4) hair, scalp |
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PE: Common complaints of the Ears
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1) hearing loss, ringing (tinnitus)
2) virtigo 3) Px/discharge |
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PE: Common complaints of the Nose
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1) drainage, congestion, sneezing, bleeding
2) symmetry, swelling, 3) tubinates, concha 4) cysts, polyps, deviation |
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PE: Common complaints of the oropharynx
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1) sore throat, hoarseness
2) gum bleeding 3) petecia, rash, swelling, plaques, 4) tonsils? |
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PE: Common complaints of the Neck
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1) swollen glands
2) goiter 3) swollen lymph nodes, masses 4) thyroid 5) symmetry |
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Types of Primary Headaches (3)?
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A. Migraine
B. Tension C. Cluster |
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Types of secondary headaches?
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A. Analgesic Rebound: normally narcotics
B. Secondary to Eye disorder C. Sinus D. Meningitis E. Subarachnoid hemorrhage F. Tumor/Mass G. Giant Cell (Temporal) Arteritis H. Posttraumatic I. Cranial Neuralgias |
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What NT is likely involved in migraines?
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Seratonin
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What process/system is likely involved in migraines?
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craniovascular modulation
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Migraines - definition
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Primary neuronal dysfunction, possibly of the brainstem origin, causing imbalance of excitatory and inhibitory neurotransmitters and affecting craniovascular modulation
* (has to do with vessale and NT that are involved, likely seratonin) |
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Migraines - presentation for each pt will be?
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* similar quality, location, associations, and prodrome
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Migraines - presentation (MC S/S)
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* Unilateral 70%. Throbbing/aching with severity variable
* Onset- rapid * 4-72 hours, 1st occurrence usually mid adolescence * nausea, vomiting, photophobia, phonophobia, aura * MC in women |
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Aura associated with visual changes called
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Scintillating Scotomas – an alteration in vision typically described as flickering or zigzagging lines or light.
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Tension Headaches may be associated with?
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muscular contractions or vasoconstriction
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Tension Headaches - presentation
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* usually bilateral, occipital, upper neck/shoulders,
* pressing or band like * onset gradual lasting minutes to weeks * |
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Tension Headaches -
* Associated, Aggravating, and Alleviating factors |
* occasionally phono and photophobia
* muscular tension * massage and relaxation |
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Cluster Headaches- Etiology
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Unknown, possibly extra cranial vasodilation from neural dysfunction with trigeminovascular pain
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Cluster Headaches- presentation
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* intense pain in cyclic patterns
* Unilateral or behind or around an eye * Deep continuous pain that is severe * rapid onset, may last minutes/hours in cyclisc fashion over weeks * MC in men |
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Clucter Headaches - Associated factors
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lacrimation, rhinorrhea, mioisis, ptosis, eye lid edema, corneal injection
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Analgesic Rebound - definition
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* due to withdrawal from analgesic (pain treating) medicine.
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Secondary to Eye disorder - definition
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* typically associated with eye musculature
* Steady and aching. |
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Sinus - definition
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* usually bi-frontal or over maxillary sinus
* throbbing |
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Meningitis - definition
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* due to infection of the meninges surrounding the brain.
* Generalized location with steady throbbing pain |
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Subarachnoid hemorrhage - definition
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* due to bleeding into the subarachnoid space.
* Generalized location with very severe pain * “the worst headache of my life” |
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Tumor/Mass - definition
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* due to displacement or traction on pain sensitive areas of the brain.
* Variable location. * Constant ache |
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Giant Cell (Temporal) Arteritis - definition
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* vasculitits from immune response of the elestin layer of the artery
* throbing, unilateral, temporal. |
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Posttraumatic - definition
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dull ache near injured area or contralateral to area of injury.
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Cranial Neuralgias - definition
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* Trigeminal Neuralgia – compression of cranial verve V, often by aberrant loop of artery or vein.
* Located over cheek, jaw, lips, or gums (divisions of the nerve 2 and 3 >1). * Shock-like, lancinating, stabbing, burning; typically severe. |
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PE of hair should include?
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Inspect: distribution, quantity, texture, foreign bodies
Palpate: texture |
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PE of scalp should include?
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Inspect: scaling, nevi, lumps/masses, rashes
Palpate: tenderness, masses |
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PE of skull should include?
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Inspect: size, contour, pain, masses, fontanels
Palpate: lumps, contour, masses, tenderness, fontanels |
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PE of face should include?
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Inspect: shape, expression, contours, symmetry, edema, masses, movements
Palpate: sinuses, parotids |
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PE of skin should include?
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Insepct: color, pigmentation, hair distribution, lesions, texture, masses
Palpate: texture, temperature |
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PE of sinuses should include?
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percuss maxillary and frontal, light
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PE findings on cushings (picture)
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PE findings on acromaglia (picture)
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PE of external eyes
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1) Lacrimal apparatus: Lacrimal gland and sac for swelling
2) Upper and lower lids 3) Width of palpebral fissures 4) Edema, color, lesions 5) Condition and direction of eyelashes 6) Adequacy of closed eyelids * Look for: Ptosis, Entropion, Ectropion, Lid retraction and Exophthalmos, sty/chalazion, Xanthelsma, Dacryocystitis, Blephritis |
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Ptosis - definition/Causes
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* Drooping of the upper eye lid.
* Causes include: myasthenia gravis, damage to the oculomotor nerve (III) (ctrls EOM and pupils), damage to the sympathetic nerve supply Horner’s syndrome. |
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Horner’s syndrome - definition and causes
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* A constellation of symptoms that result from alterations of one side of the cervical or thoracic sympathetic chain.
* Causes range from congenital, relatively benign, to serious (such as tumor as in Pancoast tumor of the lung) |
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Horner’s syndrome - S/S
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1) Unilateral
2) Ptosis 3) Possible loss of sweating on the forehead (anhidrosis) 4) Pupil constriction w/ preserved pupillary reflex |
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Eye condition often seen in Horner's syndrome
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heterochromia
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Lid retraction: Usually an area of
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visible sclera between the upper lid margin and the iris
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Exophthalmos or Proptosis- definition/causes
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* anterior displacement of the eye globe.
* Grave’s hyperthyroidism, intracranial trauma |
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Define PE findings of a Sty/Hordeolum
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* a painful, tender red infection in the gland at the margin of the eyelid
* usually well defined and on the outside of the lid |
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Define PE findings of a Chalazion
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* a subacute nontender and usually painless nodule involving a meibomian gland.
* Unlike a sty usually points inside the lid rather than on the lid margin |
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Define PE findings of a Xanthelsma
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* a slightly raised, yellowish, well-circumscribed plaque
* appear along the nasal portions of one or both eyes. * lipid disorders |
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Define PE findings of a Dacryocystitis
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* inflammation of the nasolacrimal duct by either obstruction or infection.
* painful red area over the nasolacrimal area. |
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Define PE findings of a Blephritis
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* inflammation or irritation of the eyelid or boarder.
* Characterized by red, flaking, and crusting of the eyelid margin. |
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PE of pupils -
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size, shape, symmetry, reaction to light (direct and consensual), and near reaction
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PE of the Conjunctiva and Sclera -
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Inspect with lid retracted in opposite direction of gaze:
1) Color, vascular pattern, nodules, and swelling 2) Bulbar conjunctiva 3) Palpebral conjunctiva – visualized by everting the lid |
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PE of Conjunctiva and sclera
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Color, vascular pattern
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Physical finding in Conjunctivitis -
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* diffuse dilatation of the conjunctival vessels w/ redness that tends to be maximal peripherally.
* Vision may be blurry due to discharge. * Discharge: Watery, mucoid, or mucopurulent discharge. * No change on pupils. |
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Scleral Icterus - definition
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Yellowing of the sclera indicates jaundice.
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Subconjunctival hemorrhage - definition/causes
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leakage of blood outside of the vessels, producing a sharply demarcated, red area that fades over days to yellow then disappears.
Causes: trauma, cough, sneeze from increased venous pressure |
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Physical finding of Subconjunctival hemorrhage -
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* No pain, vision not affected, pupil not affected.
* hemorrhage seen with blood in sclera |
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Pterygium - PE/definition
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* triangular thickening of the bulbar conjunctiva that grows slowly across the cornea
* Usually nasal side. May interfere with vision |
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Pinguecula - definition
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a harmless yellowish triangular nodule in the bulbar conjunctiva on either side of the iris. Does not affect vision (stops at the limbus). Direct correlation with UV exposure.
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Episcleritis - definition
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a localized ocular redness from inflammation of the episcleral vessels.
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Physical findings in Episcleritis
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* Vessels appear pink and are movable over the scleral surface. "Just a spot"
* Abrupt onset of mild pain, itching, watery eyes, * doesn’t affect vision. |
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Light reaction of the pupil test which CN?
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* Cranial nerve II afferent limb of the reflex (sensory)
* Cranial nerve III efferent limb of the reflex (motor) Check both direct and indirect reaction |
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Miosis
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pupil constriction (parasympathetic)
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Mydriasis
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pupil dilation (sympathetic)
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Near reaction test which CN?
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* Oculomotor nerve III – the pupil constricts when moving gaze from one object to another.
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Anisocoria
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Unequal pupil reaction
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Define anisocoria greater in bright light than in dim light -
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the larger pupil is unable to constrict.
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Define anisocoria is greater in dim light than in bright light -
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smaller pupil cannot dilate properly
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Causes of Dim/Bright anisocoria?
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Bright: eye trauma, open angle glaucoma, impaired parasympathetic supply to the iris ( Tonic pupil and Oculomotor nerve palsy)
Dim: Horner’s syndrome |
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Tonic Pupil and CN III palsy
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* Parasympathetic damage, absent light reaction, slow near reaction
* Fixed light reaction and near reaction, ptosis |
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Argyll Robertson's pupils - definition
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small irregular pupils that accommodate but do not react to light
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Corneal abrasion/Ulceration - definition
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injury or infection of the cornea resulting in ciliary injection
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Physical findings in Corneal abrasion/Ulceration
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* dilation of deeper vessels that are visible as radiating vessels around the limbus.
* Moderately painful, decreased vision, watery or purulent discharge. * No pupil changes. * Visible ulceration of abrasion with fluorescein staining. |
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Acute Iritis - definition
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* inflammation of the iris and the anterior chamber
* Causes: infectious and systemic disorders (autoimmune) |
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Acute Iritis - PE findings
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* Ciliary injection.
* Moderate pain * Vision decreased, minimal to no discharge. * Pupil changes – may be small and irregular. (Funking irregular pupils) |
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Open angle glaucoma - PE findings
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* Painless gradually progressive visual field loss,
* increased cup-to-disc ratio (CTD ratio) * do not have acute attacks |
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Acute closed angle glaucoma - PE findings
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* Ciliary injection
* severe aching pain * vision decreased, no discharge. * Fixed dilated pupil with steamy/cloudy cornea. * 90 degree angle light exam for crescent shadow on opposite side |
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Corneal Arcus - definition
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* a thin grayish white arc or circle near the edge of the cornea.
* Normal aging, but could represent hyperlipoproteinemia |
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Hyphema - definition
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* Blood in the anterior chamber of the eye.
* Can affect vision and cause permanent vision loss. |
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Wilson’s disease - definition
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- genetic disease in which copper accumulates in:
1) liver 2) brain 3) other tissues * causes liver, neurologic, and psychiatric manifestations |
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Wilson’s disease - PE on eye exam
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Kayser-Fleischer ring – a brownish stained ring on the edge of the iris
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Visual fields by confrontation - PE procedure
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Ask the patient to gaze at your eyes and ask to identify fingers moving. Should be similar to yours.
* Cover one eye at a time to confirm abnormalities |
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Extraocular Eye Movements (EOM): PE procedures
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* have patient follow fingers while making an roman numeral X.
* Finish with back and forth in center and accommodation test |
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Which nerves are tested during an EOM PE exam?
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CN III, IV, and VI
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CN III is tested during a EOM PE by?
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* medial movements
* laterally superior and inferior * CN - Oculomotor |
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CN IV controls which EOM muscle
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Superior Oblique - moves the eye down and inward
* CN - Trochlear |
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CN VI controls which EOM muscle?
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Lateral rectus - moves the eye laterally
* CN - Abducens |
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Esotropia - definition
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a form of strabismus in which one or both eyes point inward
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Exotropia - definition
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a form of strabismus in which one or both eyes pint outward
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Cover Test - PE procedures and findings
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* helps differentiate problematic eye and differentiate from palsy.
* The affected eye corrects with covering of none affected eye. |
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Myopia - definition
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impaired far vision (nearsighted)
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Presbyopia - definition
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impaired near vision (farsighted)
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Contraindications to mydriatic (dilating) drops
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1) head injury where pupil reactions need observance,
2) suspicion for narrow angle glaucoma |
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Papilledema - PE findings
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Disc is hyperemic and edematous, disc vessels curve over the boarders of the disc, cup not visible
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Papiledema - definition
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* due to increased intracranial pressure from disorder of the brain, meningitis, subarachnoid hemorrhage, trauma, masses.
* The increased pressure increases the edema of the optic nerve head. |
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Drusen bodies - definition
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* undigested cellular debris resulting in yellowish round spots that vary from tiny to small.
* Edges may be soft or hard |
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Drusen bodies - causes?
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normal with age, including age related macular degeneration.
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Soft Exudate: Cotton Wool patch - definition
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* white colored or grayish, ovoid lesions with irregular soft boarders.
* Usually smaller than the disc in size. * Infarcted nerve fibers |
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Soft Exudate: Cotton Wool patch - causes
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hypertension and other.
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Hard Exudates - definition
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* creamy or yellowish lesions with well define or hard boarders.
* Small and round and coalesce into larger irregular spots |
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PE findings of arteries and veins during ophthalmic scope exam?
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arteries – light red and smaller, lay over veins
veins - dark read and larger * Artery/vein crossings (AV crossing) AV nicking – seen in hypertension with hypertensive retinopathy. |
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Glaucoma Cupping - increased intraocular pressure causing increased cupping (CTD ratio >1:2)
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Drusen Bodies - normal with age, including age related macular degeneration.
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Papilledema - increased intracranial pressure from disorder of the brain, meningitis, subarachnoid hemorrhage, trauma
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Normal eye
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Hard Exudate - Diabetes and hypertension
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Cotton Wool Spots - hypertension and other.
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Superficial Hemorrhage - hypertension, papilledema, retinal vein occlusion, others
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Preretinal hemorrhage - sudden increased intracranial pressure
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Deep – Small round irregular red spots (blot hemorrhage) Causes: diabetes
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Microaneurysms - tiny round red spots, typically in macula. Causes: diabetes and other
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Neovascularization - Numerous, tortuous, narrow vessels. Causes: diabetic retinopathy
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Central Retinal Vein Occlusion - Pools of blood and indistinct margins, minimal to no vessels
* typically due to atherosclerosis of the overlying arteries leading to increased pressure & occlusion of the vein |
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Retinal Artery Occlusion - Cherry red spot on exam, pale retina
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Retinal Hemorrhage, Superficial - definition
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small linear flame shaped red streaks in the fundus
causes: hypertension, papilledema, retinal vein occlusion, others |
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Retinal Hemorrhage, Preretinal - definition/causes
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blood escapes into potential space between retinal and vitreous
causes: sudden increased intracranial pressure |
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Retinal Hemorrhage, Deep - definition/causes
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Small round irregular red spots (blot hemorrhage)
Causes: diabetes |
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Retinal Hemorrhage, Microaneurysms - definition/causes
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tiny round red spots, typically in macula
Causes: diabetes and other |
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Retinal Hemorrhage, Neovascularization - definition/causes
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formation of new blood vessels. Numerous, tortuous, narrow vessels.
Causes: diabetic retinopathy |
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Diabetic Retinopathy - definition
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deterioration of the retina due to microvascular damage that can lead to permanent vision loss.
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Stages of diabetic retinopathy?
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1) Nonproliferative Moderately Severe
2) Nonproliferative Severe 3) Proliferative – neovascularization occurs. Normal vision but risk of vision loss is high. 4) Proliferative Advanced – visual disturbance |
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Retinal Artery Occlusion - definition
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Occlusion of the retinal artery typically secondary to carotid artery disease or emboli
* Cherry red spot, emergency |
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Central Retinal Vein Occlusion - definition
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* typically due to atherosclerosis of the overlying arteries leading to increased pressure and occlusion of the vein.
* Results in increase intraocular pressure (glaucoma), neovascularization, macular degeneration, and edema |