Case Hx Flashcards
Case Hx and goal setting
Let’s the provider know how to plan the exam and helps design a plan of care
The patients goal mixed with the results from a basic eval guide what devices and strategies should be used
Your history begins when
The patient is in the waiting room
- how depends are they on the person who brought them in
- if their mobility affected by physical or visual problems
- are they alert
Important to identify the sources of the history
Always do what to the patient when getting history
Always ask the pateitn for the history. If family members or caregivers are in the room, they can add to the information
Never ignore the patient to gain history from the family member ubless the patient gives consent or it is clear that they are unable to consent
Chief complaint
- typically in the patients own words
- give a concise statement of purpose for the visit to your patient. Patients are often referred without knowing the real reason for the visit
- be positive throughout history. Don’t make unrealistic promises, but be encouraging to your patient
HPI
- detailed of the complaint
- whatvisual difficultues they experience
- task they cannot do or are having difficulty doing
- things that exacerbate the problem
- hinges that improve the problems
- details of the eye condition causing the problems
- If their vision been stable over the last 3 months
Social and personal Hx
Living situation
- alone, with sopose, with other family, in assisted living, in nursing home
Type of housing
-apartment, hours, room
Previous exposure to LVR
- previous low vision assessment
- participation in support groups
- use of magnification (Rx or OTC)
Driving for low visiion patient in history
Situations
-day, night, highways, long distances, close familiarly places
Has anyone ever told them to stop driving
Vocation/avocation
- still important to know the work a person did even if they are now retired
- how do they spend their day
- how would it be difference if their vision were better
- have they given up any hobbies because of their vision
Acitivdfits of daily living (ADLs)
Basic self care tasks
-eaitng, bathing, dressing, toileting, personal hygiene and grooming, functional mobility
Instrumental activities of daily living (IADLs)
Complex skills needed to live independently
- managing finances
- driving
- shopping
- meal preparation
- medication managment
- housework
Goals for rehab
- Reading
2. Driving
Questions to help figure out the patients goals
- if I could help you see one thing more easily, what would it be?
- what is the biggest difficulty you encounter daily because of your vision?
Clinical pearls-case history
Trying to do everything at the first visit can be time consuming and overwhelming
- at the first visit, identify the CC and one or two other important secondary issues
- once the CC has been addressed, demonstrate simple non-optical devices and prod for other problems (prodding for other problems will likely happen on follow up visit)
