opthalmological medical record, Opthalmological Medical Record

The Ophthalmological Medical Record includes:

Present Disease

  • Analytical description of the disease presented by the patient

    • Clinical examination

  • Visual acuity
  • tone
  • Cortical reflexes
  • Ophthalmobility
  • Velev-conjunctivae
  • Corneal
  • Anterior chamber
  • Irida - pupil - lens
  • Glassware
  • Bottom

    • Family - Hereditary History

  • Mother-Father-children etc

    • Previous Health Status

  • Childhood diseases - Venereal diseases
  • Imports to hospital - operations
  • Injuries-bruises
  • Gynecological history-Period (beginning-end-duration)
  • Birth - abortions etc
  • Drug Use
  • Allergies

    • Personal and Social History

  • Place of birth - accomodation
  • Religion - Education -Employment
  • Family life-problems
  • Hobbies - pets
  • Nutrition-alcohol
  • smoking-drugs consumption
  • Exposure to harmful environmental factors

    • Personal Commemorative (by systems)

  • general
  • skin
  • head - cervix
  • eyes-ears-nose-mouth-pharynx
  • breasts
  • respiratory
  • cardiovascular
  • digestive tract
  • haematopoietic - lymph nodes
  • urinary tract
  • overhead
  • nervous
  • mental functions

    • Objective Examination

  • VITAL POINTS
    • Temperature -heartbeats-breaths
  • OVERALL IMPRESSION
    • Diaphragm-View-Nutrition-Height-Weight-BMI (Body Mass Index) Bedridden/ambulatory/edemas
  • PSYCHODIANOTIVE SITUATION
    • Good/Bad informant Emotional - indolent - confusing - comatose attention - orientation - memory - speech difficulty
  • SKIN
    • Hue- turgidity - hair loss - rashes etc
  • HEAD
    • Eyes - Nose - ears - mouth - pharynx
  • NECKING
    • Movements -thyroid - trachea - lymph nodes - big vessels

    Objective Examination ΙΙ

  • BODY:
  • UPPER LIMBS:
    • Hands - palms - fingers - nails - muscle strength - joints - vessels
  • LEGS:
    • Edge - soles - fingers - claws - hammers - gastropneumonia - muscle strength - joints - vessels
  • BREASTS
  • LYMPH NODES:
    • Cervical - supergy - axillary - inguinal - others

    Objective Examination ΙΙΙ

  • RESPIRATORY:
    • Overview - attack - palpation - hearing
  • CARDIOVASCULAR:
    • Heart: thrust-tones-blasts-roots Vessels: heartbeats - blastings
  • ABDOMEN:
    • Overview - attack - palpation - hearing Liver - spleen - kidney Finger examination
  • UROPIOGENEAN MUSCULATION:
    • Muscle tone - muscle power joints
  • NERVOUS SYSTEM:
    • Consciousness - Communication - Orientation - Attitude - Buddhism Sensibility - mobility - Brain conjugations - cerebellum
     

    Expression of Interest

     
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