1.1.2- elicit detail from sig sx Flashcards
If a px has vision loss in a white eye, what follow up questions would you ask and what could this be indicative of?
Laterality: Does this affect one or both eyes/sides? (people with bilateral reduced vision may only report vision loss in the worst eye)
Onset: Did this come on suddenly or gradually? (sudden raises referral urgency)
Did this start recently, a few weeks ago or have you had this for a long time? (only useful when considering referral of Wet AMD)
Frequency/occurence: Does this occur in transient episodes lasting seconds or up to an hour? (some transient causes are very serious)
Associated/secondary symptoms: Is your vision affected in the centre, in the periphery or both? (Central = macular, optic nerve; Peripheral = serious eye or brain disease)
Do you have pain in or around your eye(s)? (Indicates serious eye or brain disease)
Do you have headaches? (Unusual headache indicates serious eye or brain cause)
Do you have eye strain (asthenopia)? (Indicates ametropia or presbyopia)
Have new floaters suddenly started appearing in your vision? (Indicates retinal detchment or vitreous haemorrhage)
Do you ever see flashes of light (photopsia) in your vision? (Indicates retinal detachment, migraine or brain disease)
Do you experience distorted vision (metamorphopsia)? (Indicates macular disease)
Do you have a tender scalp, jaw ache when chewing, ear or neck pain, weight loss, fatigue or muscle aches? - only ask if transient visual loss in patient aged over 50 years - indicates TEMPORAL ARTERITIS
Do you ever have vertigo, limb weakness or numbness? - only ask if transient visual loss - these are NEUROLOGICAL SYMPTOMS - indicates brain disease
Ocular history: Do you wear strong glasses for short sightedness (high myopia)? (Risk factor for retinal detachment)
Have you had a recent head injury (head trauma)? (Risk factor for retinal detachment)
Have you ever had eye surgery? (Risk factor for post-surgical complications such as retinal detachment)
Medical history: Do you smoke? (Risk factor for macular disease)
Do you have diabetes? (Risk factor for macular disease, vitreous haemorrhage & retinal vascular occlusion)
Do you have high blood pressure? (Risk factor for retinal vascular occlusion & TIA)
Do you have heart problems? (Risk factor for retinal vascular occlusion & TIA)
Do you take steroids? (Risk factor for posterior subcapsular cataract & glaucoma)
Family history: Does a parent or sibling have glaucoma?
Has a parent or sibling had a retinal detachment?
Does a parent or sibling have age-related macular degeneration?
Does a parent or sibling have migraine?
If a px has non-traumatic red eye, what follow up questions would you ask and what could this be indicative of?
Laterality: Does this affect one or both eyes/sides? (This will often be obvious after external examination)
Onset: Did this start recently, a few weeks ago or have you had this for a long time? (only ask when considering referral of conjunctivitis or episcleritis)
Frequency & occurrence: Is this recurrent? (Influences referral of spontaneous subconjunctival haemorrhage, aids diagnosis of recurrent corneal erosion & marginal keratitis)
Associated/secondary symptoms: Do you have reduced or blurred vision? (Indicates serious problem if not due to corneal abrasion or foreign body)
Do you have eye soreness or irritation? (May occur with bacterial or allergic conjunctivitis and dry eye)
Do you have pain in or around your eye(s)? (Indicates serious problem if not due to corneal abrasion or foreign body)
Is the pain mild or moderate to severe?
Only ask if there is pain in or around eye(s)
Can indicate seriousness (e.g. episcleritis is mild while scleritis is moderate to severe)
Are you sensitive to bright light (photophobia)? (Indicates serious problem if not due to corneal abrasion or foreign body)
Are your eyes itchy? (Indicates allergic conjunctivitis or dry eye)
Are your eyes gritty? (May occur with bacterial conjunctivitis and dry eye)
Does it feel like something is on your eye (foreign body sensation)? (Indicates corneal ulcer)
Do you see haloes around lights? (Indicates acute glaucoma)
Ocular history: Do you wear contact lenses? (Risk factor for corneal ulcer; cleaning solutions can cause allergic conjunctivitis)
Has something previously hit your eye? (Previous trauma might explain recurrent corneal erosion)
Have you ever had eye surgery? (Risk factor for endophthalmitis)
Have you had red eye with blurred vision before? (Iritis, corneal ulcer & marginal keratitis can recur)
Medical history: Do you smoke? (Risk factor for infectious corneal ulcer)
Have you had a cold recently? (May cause viral conjunctivitis)
Do you have high blood pressure? (May cause spontaneous subconjunctival haemorrhage - but rarely)
Do you have ankylosing spondylitis (May be associated with iritis)?
Do you have inflammatory bowel disease (May be associated with iritis)?
Do you have rheumatoid arthritis (May be associated with dry eye & non infectious corneal ulcer)?
Do you have asthma, hayfever or eczema (May be associated with allergic conjunctivitis)?
If a px has diplopia, what follow up questions would you ask and what could this be indicative of?
Onset: Did this come on suddenly or gradually? (Sudden or new onset raises referral urgency)
Did this start recently, a few weeks ago or have you had this for a long time? (Only useful when considering referral of wet AMD)
Frequency/Occurrence: Does this occur in transient episodes lasting seconds or up to an hour? (Indicates migraine)
Associated/secondary symptoms: Do you have reduced or blurred vision?
Follow up diplopia …
- Do you have double vision such that you see two of everything? (Diplopia often confused with ‘blurred vision’)
- Does the double vision stop when one eye is covered?
NO indicates MONOCULAR diplopia: - rules out orthoptic causes
- may be anterior eye problem, so slit lamp examination needed
YES indicates BINOCULAR diplopia - may indicate orthoptic causes that optometrists can treat
- may indicate serious eye or brain disease that requires referral
- Are the double images side-by-side, one-on-top-of-the other or both? (Only ask if diplopia is binocular)
‘side-by-side’ indicates HORIZONTAL - may indicate uncompensated phoria, convergence insufficiency, TED (Grave’s disease) or MG
- may indicate serious brain disease that causes INO, gazy palsy or nerve palsies (III or VI)
‘one-on-top-of-the-other’ indicates VERTICAL - may indicate uncompensated phoria, TED (Grave’s disease) or MG
- may indicate serious brain disease that causes INO or nerve palsies (III or VI)
‘both’ indicates OBLIQUE - may indicate uncompensated phoria, TED (Grave’s disease) or MG
- may indicate serious brain disease that causes nerve palsies (III or VI)
- Is the double vision always present or does it come and go?
‘always present’ indicates CONSTANT
‘come and go’ indicates INTERMITTENT - Does the double vision vary with no particular pattern?
- indicates migraine or dry eye
- Is the double vision more noticeable when you are looking in certain directions?
- may indicate MG
- may indicate brain disease that may cause INO, gaze palsy or any nerve palsy
- Is the double vision worse when you are tired?
- may indicate uncompensated phoria, convergence insufficiency or MG
Do you have pain in or around your eye(s)? (Indicates orbital inflammation or tumour)
Do you have headaches? (Indicates migraine), Do the headaches come with aura? (Indicates migraine)
Do you have eye strain? (Indicates asthenopia due to uncorrected refractive error or orthoptic cause)
Have new floaters suddenly started appearing in your vision? (Indicates retinal detachment)
Do you ever see flashes of light in your vision? (Indicates photopsia due to migraine or retinal detachment)
Have you noticed an increasing shadow or a loss of vision that descended like a ‘curtain’? (Indicates retinal detachment)
Do you experience distorted vision? (Indicates metamorphopsia due to wet mecular degeneration)
Do you have a tender scalp, jaw ache when chewing, ear or neck pain, weight loss, fatigue or muscle aches?
These are symptoms of temporal arteritis
Temporal arteritis can cause ischaemic nerve palsy (III, IV, VI)
(Only ask this question if there is BINOCULAR diplopia in a patient over 50 years of age)
Do you ever have vertigo, limb weakness or numbness?
These are neurological symptoms
These indicate brain disease that causes INO, gaze palsy & nerve palsy (III, IV, VI)
(Only ask this question if there is SUDDEN ONSET BINOCULAR diplopia)
Do you ever have limb muscle weakness or problems swallowing or breathing?
These are symptoms of MG
(Only ask this question if there is BINOCULAR diplopia)
Ocular history: Has something previously hit your eye? (May cause retinal detachment)
Have you had a recent head injury? (May cause nerve palsy - III, IV, VI)
Have you ever had eye surgery? (Indicates IOL disclocation if cataract surgery)
Medical history: Do you smoke? (Risk factor for ischaemic nerve palsy - III, IV, VI)
Do you have diabetes? (Risk factor for ischaemic nerve palsy - III, IV, VI)
Do you have high blood pressure? (Risk factor for ischaemic nerve palsy - III, IV, VI)
Do you have rheumatoid arthritis (May be associated with dry eye)?
Do you have asthma, hayfever or eczema? (Risk factors for keratoconus)?
Do you have an overactive thyroid gland? (Hyperthyroidism is a risk factor for TED - Grave’s disease)
Do you have multiple sclerosis? (May cause diplopia, especially due to VI nerve palsy and INO)
Family history: Has a parent or sibling had a retinal detachment? (Risk factor for diplopia due to retinal detachment)
Does a parent or sibling have migraine? (Risk factor for diplopia due to migraine)
If a px has watery, itchy, gritty eye, what follow up questions would you ask and what could this be indicative of?
Laterality: Does this affect one or both eyes/sides? (The most serious conditions, such as corneal ulcer, tend to affect one eye)
Onset: Did this start recently, a few weeks ago or have you had this for a long time? (Only ask if considering referral urgency of conjunctivitis)
Frequency & Occurrence: Is this seasonal? (Indicates allergic conjunctivitis)
Associated/secondary symptoms: Do you have reduced or blurred vision? (Indicates serious problem or raises referral urgency)
Do you have eye soreness or irritation? (Most relevant to watery eye/s but does not raise referral urgency)
Do you have pain in or around your eye(s)? (Indicates serious problem or raises referral urgency)
Are you sensitive to bright light? (Photophobia - indicates serious problem or raises referral urgency)
Are your eyes itchy? (Suggests allergic conjunctivitis but can be caused by dry eye)
Are your eyes gritty? ((Suggests dry eyes associated with chronic blepharitis)
Does it feel like something is on your eye? (Suggests foreign body sensation)
- *Ocular history**: Do you wear contact lenses?
- Risk factor for corneal abrasion or ulcer that may cause foreign body sensation or watery eye
- May have allergy to contact lens cleaning solutions (allergic conjunctivitis) that may cause itchy eyes
Do you use eye drops (NOT including pharmaceutical OTC options for dry eye and conjunctivitis)?
Allergy to these may cause itchy eyes (allergic conjunctivitis)
Has something previously hit your eye (previous eye trauma)?
Risk factor for foreign body on conjunctiva, corneal or under eyelid (something blew into the eye)
May cause ectropion due to damage to lower eyelid
Have you ever had eye surgery?
A broken suture may cause a foreign body sensation or watery eye
Medical history: Do you have rheumatoid arthritis?
May be associated with dry eye & non infectious corneal ulcer
Do you have asthma, hayfever or eczema?
Indicates allergic conjunctivitis in a person prone to allergies
Family history: Does a parent or sibling have hayfever?
There is often a family history of hayfever in sufferers of allergic conjunctivitis
If a px has floaters, what follow up questions would you ask and what could this be indicative of?
Laterality: Does this affect one or both eyes/sides? (Retinal detachment more likely if floaters occur in one eye)
Onset: Did this come on suddenly or gradually? (Retinal detachment more likely if floaters are of new onset)
Associated/secondary symptoms: Do you ever see flashes of light in your vision? (Photopsia - retinal detachment more likely)
Ocular history: Do you wear strong glasses for short sightedness (high myopia)? (Risk factor for retinal tear or detachment)
Have you ever had eye surgery? (Risk factor for post-surgical complications such as retinal tear or detachment)
Medical history: Do you have diabetes? (Risk factor for vitreous haemorrhage)
Do you have high blood pressure? (Risk factor for vitreous haemorrhage)
Do you have heart problems? (Risk factor for vitreous haemorrhage)
Family history: Has a parent or sibling had a retinal detachment?
If a px has flashes, what follow up questions would you ask and what could this be indicative of?
Laterality: Does this affect one or both eyes/sides? (Vitreoretinal cause more likely if flashes occur in one eye)
Onset: Did this come on suddenly or gradually? (Retinal detachment more likely if flashes are of new onset)
Frequency/Occurrence: Does this occur in transient episodes lasting seconds or up to an hour?
Transient causes often lack visible ocular signs - so emphasis is on detailed history and associated symptoms
If lasts seconds - migraine less likely to be cause
If lasts up to an hour - transient ischaemic attack (TIA) unlikely to be cause
Is this recurrent? (Indicates brain cause)
Associated/secondary symptoms: Have new floaters suddenly started appearing in your vision? (Indicates vitreoretinal cause)
Please describe these flashes?
Flashing or flickering lights (Indicates vitreoretinal cause)
Blurred vision with ‘zig-zag’ lines, ‘sparkling’ lights or coloured lines (Indicates brain cause)
Do you ever have vertigo, limb weakness or numbness?
- these are NEUROLOGICAL SYMPTOMS
- indicates brain disease
Ocular history: Do you wear strong glasses for short sightedness (high myopia)? (Risk factor for retinal tear or detachment)
Have you ever had eye surgery? (Risk factor for post-surgical complications such as retinal tear or detachment)
Medical history: Do you have high blood pressure? (Risk factor for TIA)
Do you have heart problems? (Risk factor for TIA)
Do you suffer from migraine?
Family history: Has a parent or sibling had a retinal detachment?
Does a parent or sibling have migraine?
If a px has vf loss, what follow up questions would you ask and what could this be indicative of?
Laterality: Does this affect one or both eyes/sides?
Unilateral (indicates retina or optic nerve disease)
Bilateral (indicates brain disease)
Onset: Did this come on suddenly or gradually? (sudden onset raises referral urgency)
Did this start recently, a few weeks ago or have you had this for a long time? (only useful when considering referral of Wet AMD)
Frequency/occurence: Does this occur in transient episodes lasting seconds or up to an hour?
Transient causes often lack visible ocular signs - so emphasis is on detailed history and associated symptoms
If lasts seconds - migraine less likely to be cause
If lasts up to an hour - transient ischaemic attack (TIA) unlikely
Is this recurrent? (Indicates brain cause)
Associated/secondary symptoms: Is your vision affected in the centre, in the periphery or both?
Purely central loss indicates macular problem
Do you have headaches? (Unusual headache indicates serious eye or brain cause)
Have new floaters suddenly started appearing in your vision?
Indicates retinal detachment if occur in one eye and accompanied by flashes
Do you ever see flashes of light (photopsia) in your vision?
Indicates retinal detachment if occur in one eye and accompanied by new onset floaters
Indicates brain cause (migraine or disease) if occur in both eyes
Have you noticed an increasing shadow or a loss of vision that descended like a ‘curtain’?
Indicates retinal detachment
Do you ever have vertigo, limb weakness or numbness?
These are NEUROLOGICAL SYMPTOMS
Indicates brain disease
Ocular history: Do you wear strong glasses for short sightedness (high myopia)? (Risk factor for retinal detachment)
Have you ever had eye surgery? (Risk factor for post-surgical complications such as retinal detachment)
Medical history: Do you smoke? (Risk factor for macular disease)
Do you have diabetes? (Risk factor for retinal vascular occlusion)
Do you have high blood pressure? (Risk factor for retinal vascular occlusion & TIA)
Do you have heart problems? (Risk factor for retinal vascular occlusion & TIA)
Do you suffer from migraine?
Family history: Does a parent or sibling have glaucoma?
Has a parent or sibling had a retinal detachment?
Does a parent or sibling have age-related macular degeneration?
Does a parent or sibling have migraine?
If a px has distorted vision (metamorphopsia), what follow up questions would you ask and what could this be indicative of?
Laterality: Does this affect one or both eyes/sides?
Onset: Did this come on suddenly or gradually? (sudden raises referral urgency)
Gradual onset in elderly person indicates dry macular degeneration, epiretinal membrane or macular hole
Sudden onset in elderly person indicates wet macular degeneration
Did this start recently, a few weeks ago or have you had this for a long time? (only useful when considering referral of Wet AMD)
Medical history: Do you smoke? (Risk factor for macular disease)
Do you have diabetes? (Risk factor for macular disease)
Do you have high blood pressure? (Risk factor for central serous retinopathy)
Do you have heart problems? (Risk factor for central serous retinopathy)
Family history: Does a parent or sibling have age-related macular degeneration?
If a px has pain in/around eye, what follow up questions would you ask and what could this be indicative of?
Laterality: Does this affect one or both eyes/sides?
Onset: Did this come on suddenly or gradually? (sudden onset raises referral urgency)
Frequency/occurence: Does this occur in transient episodes lasting seconds or up to an hour? (some transient causes are very serious)
Transient causes often lack visible ocular signs – so emphasis is on detailed history and associated symptoms
Is this recurrent? (some recurrent causes are very serious)
Associated/secondary symptoms: Do you have reduced or blurred vision?
presence of blurred vision helps determine whether eye is likely source of pain
Do you have double vision such that you see two of everything?
indicates diplopia - but is it binocular diplopia?
Does the double vision stop when one eye is covered?
only ask this question if diplopia is reported
indicates binocular diplopia - presence of binocular diplopia helps determine whether eye is likely source of pain
Do you have ‘shooting’ or ‘electric’ pains?
determine the nature of the pain
suggests trigeminal neuralgia - referred pain i.e. the source of pain is not the eye
Do you have pain when you move your eyes?
determine the nature of the pain
suggests optic neuropathy
Do you have headaches?
unusual headache indicates serious eye or brain cause
Are you sensitive to bright light?
photophobia - indicates serious eye disease
Do you ever see flashes of light in your vision?
suggests migraine or brain disease - referred pain i.e. the source of pain is not the eye
Do you have a tender scalp, jaw ache when chewing, ear or neck pain, weight loss, fatigue or muscle aches?
only ask if patient aged over 50 years
indicates TEMPORAL ARTERITIS
Do you ever have vertigo, limb weakness or numbness?
these are NEUROLOGICAL SYMPTOMS
indicates brain disease
Do you see haloes around lights?
indicates serious eye disease i.e. acute glaucoma
If a px has headaches, what follow up questions would you ask and what could this be indicative of?
Laterality: Does this affect one or both eyes/sides?
Onset: Did this come on suddenly or gradually? (sudden indicates sinister headache)
Frequency/occurence: Does this occur in transient episodes lasting seconds or up to an hour? (some transient causes are very serious)
Transient causes often lack visible ocular signs - so emphasis is on detailed history and associated symptoms
Is this recurrent?
Associated/secondary symptoms: Do you have reduced or blurred vision? (may indicate serious eye or brain disease)
Do you have pain in or around your eye(s)? (may indicates sinister headache)
Please describe your headaches:
unusual
indicates sinister headache
almost every day (>15 times a month), gets patient down (high impact on daily activities)
indicates CDH
about once a fortnight (<15 times a month), gets patient down (high impact on daily activities)
indicates moderate/severe migraine
occasional headaches that do not bother patient much (low impact on daily activities)
indicates ETTH or mild/moderate migraine
Do the headaches get worse when you lie down? (indicates raised intracranial pressure)
Do the headaches come with aura? (indicates migraine)
Do you ever see flashes of light in your vision? (photopsia - indicates migraine or brain disease)
Do you have a tender scalp, jaw ache when chewing, ear or neck pain, weight loss, fatigue or muscle aches?
- only ask if patient aged over 50 years
- indicates TEMPORAL ARTERITIS
Do you ever have vertigo, limb weakness or numbness?
- these are NEUROLOGICAL SYMPTOMS
- indicates brain disease
Medical history: Do you suffer from migraine?
Family history: Does a parent or sibling have migraine?
If a px has a rash around the eye, what follow up questions would you ask and what could this be indicative of?
Laterality: Does this affect one or both eyes/sides? (this will be evident from gross external examination)
Onset: Did this come on suddenly or gradually? (causes of rash around the eye are usually sudden onset)
Associated/secondary symptoms: Do you have reduced or blurred vision? (raises referral urgency)
indicates complications of HZO eg corneal ulcer, acute glaucoma, optic neuropathy
Do you have pain in or around your eye(s)? (raises referral urgency)
indicates complications of HZO eg corneal ulcer, acute glaucoma, optic neuropathy
Are you sensitive to bright light? (photophobia - raises referral urgency)
indicates complications of HZO ie corneal ulcer
Ocular history: Do you use eye drops?
can cause rash around eye due to contact allergy/dermatitis
If a px has an abnormal eyelid position, what follow up questions would you ask and what could this be indicative of?
Laterality: Does this affect one or both eyes/sides? (this may be evident from gross external examination)
Onset: Did this come on suddenly or gradually?
Associated/secondary symptoms: Do you have reduced or blurred vision? (raises referral urgency)
Do you have double vision such that you see two of everything?
indicates diplopia - but is it binocular diplopia?
ptosis can mask diplopia in III nerve palsy
Does the double vision stop when one eye is covered?
only ask this question if diplopia is reported
indicates binocular diplopia (raises referral urgency)
Is the double vision worse when you are tired?
only ask this question if diplopia is reported
indicates MG
Do you have eye soreness or irritation?
raises referral urgency of ectropion
Do you have pain in or around your eye(s)? (raises referral urgency)
Do you have head & neck pain?
most relevant to ptosis with miosis on one side (Horner’s syndrome)
indicates risk of stroke due to carotid artery dissection
Do you ever have limb muscle weakness or problems swallowing or breathing?
only ask if bilateral ptosis is present
indicates MG
Ocular history: Has something previously hit your eye? (eye trauma may cause ectropion due to skin scarring)
Have you had a recent head injury? (head trauma may cause ptosis due to III nerve palsy)
Have you ever had eye surgery? (may cause ectropion due to skin scarring)
Medical history: Do you smoke? (Risk factor for ischaemic III nerve palsy that can cause ptosis)
Do you have diabetes? (Risk factor for ischaemic III nerve palsy that can cause ptosis)
Do you have high blood pressure? (Risk factor for ischaemic III nerve palsy that can cause ptosis)
Do you have an overactive thyroid gland (hyperthyroidism - Grave’s disease - may cause lid retraction)
If a px has red swollen eyelid(s), what follow up questions would you ask and what could this be indicative of?
Laterality: Does this affect one or both eyes/sides? (this will be evident from gross external examination)
Onset: Did this come on suddenly or gradually?
Associated/secondary symptoms: Do you have reduced or blurred vision? (raises referral urgency)
may indicate orbital cellulitis if severely swollen lid on one side
may indicate complications of HZO eg acute glaucoma, optic neuropathy
Do you have double vision such that you see two of everything?
indicates diplopia - but is it binocular diplopia?
Does the double vision stop when one eye is covered?
only ask this question if diplopia is reported
indicates binocular diplopia (raises referral urgency)
indicate orbital cellulitis if severely swollen lid on one side
ptosis can mask diplopia in orbital cellulitis
Do you have pain in or around your eye(s)? (raises referral urgency)
may indicate orbital cellulitis if severely swollen lid on one side
may indicate complications of HZO eg corneal ulcer, acute glaucoma, optic neuropathy
Are you sensitive to bright light? (photophobia - raises referral urgency)
indicates complications of HZO ie iritis or corneal ulcer
Are your eyes gritty?
indicates blepharitis
Does it feel like something is on your eye?
foreign body sensation may occur with blepharitis
Do you feel unwell or have a fever?
indicates orbital cellulitis if there is a severely swollen lid on one side
Ocular history: Do you use eye drops?
can cause rash around eye due to contact allergy/dermatitis
If a px has eyelid lump(s), what follow up questions would you ask and what could this be indicative of?
Laterality: Does this affect one or both eyes/sides? (this will be evident from gross external examination; lid lumps are usually unilateral)
Onset: Has this grown slowly over a period of months or rapidly? (progressive growth over months raises chance of malignancy)
Medical history: Have you ever had skin cancer? (previous skin cancer is risk factor for malignancy of lid lump)
Do you spend a lot of time outside in the sun? (extensive sun exposure is risk factor for malignancy of lid lump)
If a px has eyelid spasm, what follow up questions would you ask and what could this be indicative of?
Laterality: Does this affect one or both eyes/sides? (this will be evident from gross external examination)
unilateral - indicates myokymia or hemifacial spasm
bilateral - indicates myokymia or blepharospasm
Onset: Did this start recently, a few weeks ago or have you had this for a long time?
recent onset raises referral urgency of blepharospasm and hemifacial spasm
Type/severity: Is this constant or intermittent?
constant - indicates blepharospasm or hemifacial spasm
intermittent - indicates myokymia
