History & Symptoms Flashcards
What are the Advantages of Electronic Patient Records?
1) Avoid problem of illegal record cards.
2) Information from previous test can be uploaded then amended with information from current examination.
3) Record can be linked to digital ocular photography and other equipment.
4) Referral letters easier to produce and print.
5) Reduce the likelihood of lost records which are common with paper records.
6) Alleviates bad handwriting
What are the Disadvantages of Electronic Patient Records?
1) Inability to sketch features if desired like a lesion, cataract, fluorescein staining patterns for example.
2) Different types of system require adaptation which can be difficult for locums.
3) Time consuming to scan in old record cards.
4) Fragmented nature of information means it can be difficult to highlight key details,
Case History
The first and most important element of an eye examination.
What elements should the Case History include?
1) General information
2) Last eye examination and Where
3) Reason for Visit (RFV)
4) Symptoms (Sxs)
5) Ocular history (OH)
6) General health (GH)
7) Family Ocular History (FOH)
8) Family Medical History (FMH/FGH)
9) Occupation, hobbies & Driving
GENERAL INFORMATION
- Date of Eye Examination
- Title – Mr/Mrs/Miss/Ms/Dr/Prof
- Surname
- Forenames
- Date of Birth – to calculate Age
- Address – including postcode
- Telephone No – home, work, mobile
- GP name & Address
- Previous Optometrist
General Observation of Px:
- Thin, ‘twitchy’
- Overweight, ruddy-faced
- Abnormal head position
- Facial Asymmetry
- Eyelids
- Eyes
- Overactive Thyroid = Hyperthyroidism
- Hypertension
- Binocular Visual Defect
- Congenital Anomalies
- Lesions, Ptosis, Epiphora
- Nystagmus, Strabismus
What other things should you pay attention to?
- Overall physical appearance
- Mobility
- Speech, intelligence and Emotional state.
What 3 factors can influence the prevalence of some ocular disorders?
- Age
- Gender
- Race
RFV
Establishes the Chief Complaint - CC
The examination should attend to this CC as a priority plus any secondary complaints that are mentioned.
What comprehensive approach is best to adopt when conducting H&S?
Problem-oriented Approach
Problem-oriented Approach allows you to _______
- Consider a list of Tentative Diagnoses
- Ask more questions and Probe at Differential Diagnosis
- Start by asking an Open-ended Question like:
“Do you have any problems with your vision or your eyes? - Obtain a full description of the CC using LOFTSEA.
What does
LOFTSEA
stand for?
L - Location | Laterality O - Onset F - Frequency and Occurrence T - Type and Severity S - Self-treatment and its Effectiveness E - Effect on you A - Associated and Secondary Sxs
Location | Laterality
If CC is Headache (H/A), Ask ______
If CC is Blurred Vision, Ask _______
If CC is Diplopia, Ask ________
“Where does it hurt?”
“Are both eyes affected?”
“Does this happen when you are looking in any particular direction?”
Onset
Ask __________
Ask __________
“When did this start happening?”
“Did it occur suddenly or gradually?”
Sudden Onset may indicate _______
Serious pathology
Long duration may indicate ________
Problem is not having a significant effect on patient due to lack of severity.
Frequency and Occurrence
Ask ___________
Ask ___________
“How often does this happen?”
“How long does this last?”
If the problem is of Visual Origin, then they tend to occur….
- When using eyes i.e. reading, watching TV, driving
- During weekdays more than weekends
- Starts in the middle of the day and gradually get worse
Type and Severity
If CC is H/A, Ask _________
If CC is Blurred Vision, Ask __________
If CC is Diplopia, Ask ___________
“Is it a throbbing/sharp or dull H/A?”
“Is the blur constant or intermittent?”
“Was the vision loss partial or total?”
“If the Double Vision one on top of the other or side by side?”
“Does the Double Vision disappear when one eye is closed?”
Self-treatment and its Effectiveness
Ask __________
Ask __________
“Does anything make it go away?”
“How well does this work?”
Medication
Note down:
Dosage
How frequently they took it
Effect on Patient
Ask __________
Ask __________
Ask __________
“Does this affect how well you can do certain things?”
“Have you been to see your GP about this?”
“Has this restricted your ability to drive?”
The responses to the “Effect on Px” section may….
dictate Patient management
Associated or Secondary Symptoms
Ask ___________
“Are you having any other difficulties?”
Symptoms
Some Sxs may already have emerged in the RFV.
However, ALL Patients should be Asked:
- DV and NV
- Asthenopia
- Headaches
- Pain or Burning
- Diplopia
- Flashes
- Floaters
What does Constant DV Blur
indicate?
Myopia
Nuclear Sclerosis
What does Intermittent DV Blur
indicate?
Young Diabetics
Pseudomyopes
What does Intermittent NV Blur
indicate?
Presbyopia
What does DV and NV Blur
indicate?
Astigmatism
Pathology
Asthenopia has 2 causes….
- Visual causes
2. Pathological causes
What are the Visual Causes for Asthenopia?
- Ametropia
- Accommodative Dysfunction
- Presbyopia
- Binocular Anomaly
- Poor illumination
What are the Pathological Causes for Asthenopia?
- Ocular inflammation
- Retinal Disease
When asking about Headaches, what should you follow up with?
Are the H/As related to Vision?
Vision-related H/As tend to be:
- Associated with the use of eyes
- Mild/moderate, dull, non-throbbing nature.
- Located Occipital or Temporal
Pain or Burning can commonly be a symptom of _____
Dry Eye
Ocular Discomfort can also be related to:
- Tear Anomalies
- Side effect of Medication for Hypertension
- Associated with Arthritis
- Ocular Inflammatory Conditions
What should you ensure when asking about Diplopia?
Patient is aware of the difference between Double Vision and Blurred Vision.
How can you confirm this?
“Do you see two of everything or does everything seem blurred?”
If Diplopia, Ask _________
“Does the double vision disappear when one eye is closed?”
If yes ______-
then Binocular Diplopia
Pathological / Traumatic Diplopia is most often
Vertical
What are Floaters?
Normal age-related change that occurs when the Vitreous liquefies and shrinks, creating visible microscopic fibres.
Flashes or also called _______-
Photopsia
OH
Comprised of:
- Present refractive correction
- Spectacles
- Contact lenses
- Lower Visual Aids (LVA) e.g. magnifying glass
- Previous eye treatment
- Injuries, infections, surgery, treatment like patching, squint surgery
- Last eye examination (LEE)
What are 2 important questions to ask in Ocular History?
“Have you ever had any eye injuries, infections, surgery or any other treatment?”
“Have you ever had vision training or eye patching?”
GH
Comprised of:
- Medical History
- Medication
- Allergies & Hypersensitivities
For Medical History what are the 2 most important conditions that need to be asked about?
- Diabetes
2. Hypertension
Clinical relevance in Medical History
Systemic Diseases such as:
Diabetes (IDDM & NIDDM)
Hypertension (↑BP)
Arthritis
Thyroid disorders have Ocular Manifestations.
Medication
Key Question, Ask ______
“Are you taking any medicines, eyedrops or pills?”
- Px may NOT consider that drops that whiten the eyes, hay fever pills or birth control pills are medication.
Clinical relevance in Medication
Many systemic medications can have ocular side effects or may interact with the topical diagnostic drugs Optometrists use.
Give examples of how Systemic Drugs may affect the eyes:
Beta-blocker prescribed for Systemic Hypertension can cause Dry eyes which will have implications for successful CLW.
Oral Corticosteroids can cause Posterior Subcapsular Cataracts.
Topical eye drops for Hayfever will have implications for CLW and should be instilled at least 20 minutes before lens insertion.
What is the key relationship when it comes to Medication?
Typically, the higher the dosage of the drug and the longer the patient has been taking it, the more likely there are adverse ocular effects.
What 2 Questions should you ask in Allergies?
“Do you suffer from any allergies?”
“Have you ever had a bad reaction to medicine or eye drops?”
Clinical relevance in Allergies & Dry Hypersensitivity
Allergies can cause eye irritation and influence tolerance to CLs.
Drug Hypersensitivity may occur with topical diagnostic drugs used by Optometrists.
What 3 things should you be aware of in Drug Hypersensitivity?
- Dilation drops
- Diagnostic dyes
- Local Anaesthetics
FOH
“Has anybody in your family had any eye problems such as lazy eye or Glaucoma?”
Clinical Relevance in Family Ocular History
Some eye abnormalities are inherited:
The prevalence of Strabismus:
- Increases if one parent has strabismus
- Increases again if both parents have strabismus
- TRIPLES
- The prevalence of Primary Open Angle Glaucoma (POAG): increases if a parent or sibling has POAG
FMH
“Has anybody in your family had any medical problems such as high blood pressure or Diabetes?”
Clinical Relevance in Family Medical
History
Some systemic diseases that show ocular manifestations are hereditary.
The prevalence of Hypertension:
- Increases if one parent has hypertension
- Increases again if both parents have hypertension
- TRIPLES
The prevalence of NIDDM:
- Increases if one parent has NIDDM
- Increases again if both parents have NIDDM
- Increases if a sibling has NIDDM
IDDM
Insulin Dependent Diabetes Mellitus
NIDDM
Non-Insulin Dependent Diabetes Mellitus
Type 1 Diabetes =
IDDM
Type 2 Diabetes =
NIDDM
Other
Ask _______
- “What is your Occupation?”
- “Do you have any Hobbies?”
- “Do you play sports regularly?”
- “Do you drive?”
- “Do you smoke?”
- “Do you use the VDU?”
Clinical Relevance for Other
Need to establish patients Visual demands like:
Do they need:
- Safety eyewear
- CLs
- Separate Spex
Smoking is the strongest environmental risk factor for ____
ARMD
Record positive and negative Px responses:
From legal viewpoint, no recorded response means question not asked.
If the cause of the CC is not determined, then present your negative findings in a positive manner.
For example, non-ocular headaches:
“I do not believe your headaches are due to a problem with your eyes or vision, Mr Wiggins.
Your eyesight is excellent and there is no need for glasses/change in glasses, your eye muscles and focusing muscles are all working normally and are working well together and there is no sign of eye disease from any of the tests that I have performed.”
Myodesopsia
Perception of Floaters
Reduced Vision
Transient loss of vision
What would you associate with Visual Migraine?
- Lasts 10-30minutes
- Dark spot in vision which moves and grows
- Zigzagging lines
- Binocular
Which Peripheral Degeneration is pre-disposing for Retinal Detachment?
Lattice Degeneration
What advice should you give a patient with a recent-onset PVD?
- PVD is a normal occurence with Aging
- It is caused by Vitreous Syneresis
- This causes the Vitreous to pull away from its attachment creating a new floater.
- In very rare cases, the vitreous can cause a retinal tear when it pulls away.
- You are at higher risk of this for 6 weeks following a PVD.
- The warning signs of a RD are continually increasing floaters.
- Increasing flashing lights in your vision
- And a curtain or vein coming over your vision.
- If you experience these Sxs you need to ensure you seek medical attention so its investigated within 48hrs.
How can glare reduce Visual Acuity?
- Reduction of brightness of the rest of the scene by constriction of the pupils.
- Reduction in contrast of the rest of the scene by scattering of the bright light within the eye.
- Reduction in contrast caused by scattering light in particles in the air.
- Reduction in contrast by reflection of bright areas on the surface of a transparent medium e.g. glass, plastic, water = Veiling glare
- Bloom surrounding objects in front of glare.
Transient Visual Obscurations (TVOs)
These are often described as momentary grey spots, or a dimming or blackout of vision that occur in one or both eyes, especially after a change in position (such as standing up from a seated position).
Postural Hypotension / Hypertension:
A condition in which a person’s blood pressure drops/increases abnormally when they stand up after sitting or lying down.
General health:
Ideal Answer
Fit and well. No diagnosed systemic conditions. No cardiovascular or metabolic disorders (i.e. no diabetes). No allergies. No medication.
In general, vision loss can be caused by the following:
- Refractive error.
- Binocular vision anomalies (strabismic and non-strabismic).
- Opacities of the ocular media.
- Central retina disorders.
- Optic nerve disorders.
- Intracranial disorders that impact on the visual pathway.
Temporal Artiertitis Sxs:
- Jaw Claudication
- Malaise
- Scalp tenderness
- Polymyalgia Rheumatica
- Temporal Headaches - Persistent
- Vision loss or Diplopia
