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It is used for alert (conscious) people, but often much of this information can also be obtained from the family or friend of an unresponsive person. In the case of severe trauma, this portion of the assessment is less important. A derivative of SAMPLE history is AMPLE history which places a greater emphasis on a person's medical history. [2]
A medical diagnosis for the purpose of the medical visit on the given date of the note written is a quick summary of the patient with main symptoms/diagnosis including a differential diagnosis, a list of other possible diagnoses usually in order of most likely to least likely. The assessment will also include possible and likely etiologies of ...
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Family medical history FOH: Family ocular history F/U: Follow up appointment GH: General health G(M)P: General (medical) practitioner HA: Headaches HARC: Harmonious abnormal retinal correspondence HM: Hand motion vision – state distance Hx: History IOL: Intra-ocular lens IOP: Intra-ocular pressure ISNT: Inferior, Superior, Nasal, Temporal
The pupil is a hole through which the eye's interior can be viewed. For better viewing, the pupil can be opened wider (dilated; mydriasis) before ophthalmoscopy using medicated eye drops (dilated fundus examination). However, undilated examination is more convenient (albeit not as comprehensive), and is the most common type in primary care.
System: Eye and visual system: Significant diseases: Cataract, retinal disease (including diabetic retinopathy and other types of retinopathy), glaucoma, corneal disease, eyelid and orbital disorders, uveitis, strabismus and disorders of the ocular muscles, ocular neoplasms (malignancies, or cancers, and benign eye tumors), neuro-ophthalmologic disorders (including disorders of the optic nerve)
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Pre-hospital emergency medicine (abbreviated PHEM), also referred to as pre-hospital care, immediate care, or emergency medical services medicine (abbreviated EMS medicine), is a medical subspecialty which focuses on caring for seriously ill or injured patients before they reach hospital, and during emergency transfer to hospital or between hospitals.