1.1.2: Elicits detail & relevance of significant symptoms Flashcards
What questions would you ask if px presented with vision loss in a white eye?
➢ Does this affect one (R/L) or both of your eyes?
➢ Did this come on suddenly or gradually?
➢ Did this start recently, few day/weeks ago or have you had this a long time?
➢ Is it constant or occur in episodes lasting a few seconds/hours?
➢ Is the vision affected in the centre, periphery or both?
➢ Do you have any pain in or around the eyes?
➢ Do you have headaches?
➢ Do you have eye strain (asthenopia)?
➢ Have new floaters suddenly started to appear in your vision?
➢ Do you see flashes of light (photopsia) in your vision?
➢ Do you experience distorted vision (metemorphopsia)?
➢ Do you have a tender scalp, jaw ache when chewing, ear or neck pain, weight loss, fatigue (GCA)?
➢ Do you ever have vertigo, limb weakness or numbness (stroke)?
What questions would you ask if px presented with a red eye?
➢ Does this affect one (R/L) or both of your eyes?
➢ Did this start recently, few day/weeks ago or have you had this a long time?
➢ Is this first time or recurrent?
➢ Do you have reduced or blurred vision?
➢ Do you have any soreness or irritation?
➢ Do you have pain in or around the eye?
➢ Is the pain mild, moderate or severe?
➢ Are you sensitive to bright lights (photophobia)?
➢ Are your eyes itchy?
➢ Are your eyes gritty?
➢ Does it feel like there something in your eye?
➢ Can you see haloes around lights? (enquire about headaches and nausea too)
OH:
➢ Do you wear CLs?
➢ Any recent trauma to head or eyes?
➢ Have you had any eye surgery?
➢ Have you had anything like this before?
GH:
➢ Recent Cold?
➢ HBP or blood thinners?
➢ Inflammatory bowel disease?
➢ Rheumatoid Arthritis?
➢ Asthma, Hayfever or Eczema?
What questions would you ask if px presented with diplopia?
➢ Do you have double vision such that you see two of everything?
➢ Does the double vision stop when one eye is covered? (Mono/Bino)
➢ Are the double imaged side by side, one on top of the other or both?
➢ Is the double vision always present or does it come and go?
➢ Is the double vision more noticeable when looking in a certain direction?
➢ Is the double vision worse when you’re tired?
What questions would you ask if px presented with headaches?
➢ Where is your headache located (Frontal, Temples, Top of head, LHS, RHS, Back of head)?
➢ When does it tend to come on (any time of day or particular activity)?
➢ How often do you get a headache (times a week/month)?
➢ How long do they last?
➢ What kind of pain is it (sharp, stabbing, throbbing, dull)?
➢ How severe is the pain?
➢ Do you take any medication to relieve it? Does it help?
➢ How is it affecting your daily life? (e.g. Can carry on as normal, debilitating, signed off work etc.)
➢ Do you have reduced or blurry vision?
➢ Is the headache a dull ache or more moderate/severe pain?
➢ Does the headache worsen when bending over or lying down?
➢ Do the headaches come with an aura?
➢ Do you see flashes of light?
➢ Do you feel any nausea?
➢ Do you ever wake up from the headache?
➢ Do you have a tender scalp, jaw ache when chewing, ear or neck pain, weight loss, fatigue (GCA)?
➢ Do you ever have vertigo, limb weakness or numbness (Stroke)?
Which tests should you perform in px with headaches?
- BCVA
- Ocular Motility + Cover Test -> checking for tropia/phoria/palsy that may explain h/a
- Visual Fields (enlarged blind spot in Papilloedema, Altitudinal Defect with AION)
- Colour Vision (Optic Neuritis dyschromatopsia)
- Pupils (RAPD)
- Ptosis (Horner’s)
- Slit Lamp and Van Herick’s
- Palpitation of Temporal Arteries (absence may indicate GCA)
- OCT is useful for Papilloedema
How does a migraine usually present?
- FH
- Unilateral
- Pulsating Pain
- Lasts few hours – days
- Photophobia
- Phonophobia
- Fatigue
- Neck Stiffness
- Blurred Vision
- May have associated aura:
o Zigzaged lines
o Flashing Lights/Spots/Lines
o Loss of Vision
o Scotoma
o Pins and Needles - Numbness
How does a tension headache usually present?
- Bilateral
- Pressing/Tightening
- Mild-Moderate Intensity
How do cluster headaches usually present?
- Short Lasting: 15-3hrs
- Severe Pain
- Unilateral
- Neuralgiform Headache
- Conjunctival Injection, Lacrimation or nasal congestion
- Sweating
- Miosis
- Ptosis
- Lid Oedema
How does a headaches due to refractive error/uncorrected phoria/tropia usually present?
- Recurrent
- Frontal
- Absent on waking
- Blurred vision/difficulty adjusting to visual focus from distance to near
- Rapid improvement with refractive correction
How does Giant Cell Arteritis (GCA) usually present? (A&E)
Classic presentation:
* New severe headache (maybe worse on standing up)
* Temporal artery - prominent, inflamed, non-pulsatile
* Loss of vision in one/both eyes
* scalp tenderness
* pain on jaw claudication (discomfort chewing),
* proximal myalgia (muscle pain)
* weight loss
* Malaise
* Eye pain/orbital pain (rarer symptom)
possible symptoms:
* Amaurosis fugax (transient blurred vision),
* Transient diplopia
* Cranial nerve palsies
How does Raised Intracranial Pressure usually present? (A&E)
Cerebrospinal Fluid in the subarachnoid space leads to swelling of the optic nerve head
(papilloedema).
* Causes of raised intracranial pressure
* Intracranial space occupying lesion (abscess, brain tumour),
* Intracranial haemorrhage (stroke, trauma),
* Hydrocephalus
* Meningitis
* Dural venous sinus thrombosis
* idiopathic (pseudotumour cerebri)
Presentation:
* Headache (diffuse, constant, aggravated by coughing/straining/bending/lying
down, worse in morning)
* Blurred vision - induced hyperopia
* Transient visual obscuration of vision (postural)
* Photopsia (perceived flashes of light)
* Transient/persistent diplopia
* Bilateral swelling of optic nerve head
* Nausea and vomiting
* Pulsatile tinnitus - whooshing
How does Idiopathic Intracranial Hypertension usually present? (A&E)
- Obesity association (overweight women)
- Swollen discs
- Headaches
- Visual obscuration
- Normal appearance on brain imaging, high opening pressure on lumbar puncture
with normal CSF consistency - Risk of blindness + debilitating headaches= so ensure this patient is seen to
How does Carotid Artery Dissection usually present (A&E)?
Split in vessel wall of carotid artery leading to a complete occlusion of the lumen, resulting in reduced blood flow/clot formation: a cerebrovascular accident (stroke)
Presentation
* Headache
* Gradual
* Deteriorates in severity
* Scalp tenderness
o pain in area around arm and neck.
o Ipsilateral horner’s syndrome
* characterised by:
o miosis (constriction of the pupil),
o ptosis (drooping of the upper eyelid),
o anhidrosis (absence of sweating of the face)
* Neurological signs (i.e. limb weakness, speech disturbances, visual field loss)
* Possible visual field loss (from ischaemic optic neuropathy, retinal artery
occlusion)
* Possible diplopia
How does Subarachnoid Haemorrhage usually present? (A&E)
Medical emergency, fatal in 50% of px within 24 hours
Cause:
Leakage of blood from an arterial wall defect of the middle of cerebral artery (majority of cases).
Also caused by
* venous bleeds,
* clotting disorders
* haemorrhages due to anticoagulants.
Presentation:
* Thunder-clap headache
o Onset = split second
o Described as: ‘worst ever headache’ the patient has experienced
Location: occipital (back of head)
Other associated symptoms:
* neck stiffness
* loss of consciousness
* agitation
* nausea
* vomiting
* Resembles acute attack of meningitis
Ocular manifestations:
* optic nerve head swelling,
* 6th nerve palsy
* Terson’s Syndrome (Haemorrhage (pre-retinal, vitreous) with a subarachnoid haemorrhage)
How does Trigeminal Neuralgia usually present?
Idiopathic/secondary to compression by tumour/aneurysm/secondary to MS
* Persistent/recurrent/unilateral/periocular
* Electric shock-like quality or unpleasant ‘pins and needles’/ants crawling under skin sensation
* Decreased corneal or facial sensation
* Anisocoria
