History & Symptoms - CSA Flashcards
Why do we bother taking history and symptoms?
First off we don’t know anything about the patient
Need to identify any problems
Ascertain a baseline - find out what is normal for them.
Need to ensure proper tests are included - (if you do the tests in order of history and symptoms you won’t miss any tests out)!
Establishes a good rapport
Makes you appear as if you know what your doing
For the sake of litigation
What is an open question?
A question where the answer cannot simple be yes or no. There is no limited choice on response.
What is a closed question?
A question where the answer can only be yes, no or limited responses.
What is funnel questioning?
Where you start with an open question.
Response
Then narrow question done.
Then get your response.
What information are you looking to record for history and symptoms of a patient?
Reason for attendance Last eye examination Current optical and optical status Symptoms Previous ocular history Ocular history (family) General medical history (family) e.g. Diabetes General Health Medication Allergies Lifestyle and Occupation
What are the three categories of symptoms?
What the patient sees or doesn’t see
What the patient sees when they look in the mirror
What the patient feels
What are typical patient complains?
Visual complaints Pain, Ache Redness, Congestion , Inflammation Crustiness, flakes on lids Lumps, mass, swelling Eyelid problems Squint, nystagmus Visual defects
What are the most common reasons patients will come to see you in practice?
In order of most common:
Blurred vision at near Non specific ocular discomfort/fatigue Burning/tearing of eyes Blurred vision at distance No complaint: request for routine check up/ new frame No complaint: Broken/lost glasses
What are the most common symptoms in order of frequency?
Headache (no ocular association) Headache (with ocular association) Conjunctivitis, blepharitis (crusting and flaking) Lid twitching; itchy eyes Photophobia Ocular pain Loss of vision (uniocular, binocular, and scotomas) Exophthalmos (uniocular or binocular) Diplopia (Double vision) Anisocoria Photopsia (flashes of light) and halos Strabismus Jumping of words and other difficulties when reading Chromatopsia (Disturbance of colour vision) Vertigo Foreign body in eye
What is the difference between a symPtom and sign?
symPtom —> what the Patient sees
sign—> what the optometrist sees
What are general rules for when you see patients?
-Treat as would like to be treated • People older than you call Mrs X • Dress appropriately • From a patients POV: Sharper suit = better eye test • Harder to sue if like you
What should you do when you enter the treating room?
Make sure room is tidy.
Equipment is all out and turned on.
When a patient comes in what must you do?
Guide the patient to where you want them to sit.
“Take a seat in the big black chair”.
Observe the patient when they walk in.
What general observations should you make of the patient upon first meeting?
- Whether they are a Spectacle wearer
- Head posture - are they tilting their head to guide themselves towards the chair when they walk in
- Lids – ptosis, asymmetry, lesions
- Strabismus
- Facial asymmetry (iris and/or pupil e.g. anisocoria )
- General well-being
What is anisocoria?
Unequal pupil sizes
What can we work out from the general observation of a right eye that turns in?
Right eye has strabismus.
Would expect poorer vision in the right eye.
Right eye is amblyopic (unable to focus as well - lazy eye)
No tests that involve binocularity are needed.
How can a stroke affect vision?
It could leads to double vision or even hemianopsia.
What may be reasons for visit?
Perhaps more than one reason Reason for visit Crucial information Reminder/normal interval Visual problems Dispensing problems - they can't see out of the pair of glasses they were prescribed. Headaches Preventative e.g. for child
Why is it important recall when the last eye examination was?
So you can record any changes that have occurred e.g:
Myopia, astigmatism, hyperopia Cataract IOP Presbyopia etc Rx out of date
This allows you to determine whether that change from last eye appointment is normal
What kind of questions do you start talking to a patient with?
Introductory questions e.g:
• Hello. Why have you come to see me today? Are you having any problems? • When was your last eye test? - Are you having an problems?
After asking introductory questions what type of questions do you want to ask next and make note of?
Vision related questions in order:
• Ask if they have any problems with:
• Distance Vision with or without Rx
• Relate this to normal distance tasks
e.g. driving, TV, cinema etc
• Ask if they have any problems with:
• Intermediate Vision
• Check what Px does at this distance
e.g. computer and music
• Ask if they have any problems with: • Near Vision • What distance that they work at? • What near tasks are involved? •
Ask what their hobbies and occupation are and relate this to their vision.
What is important to remember when asking vision related questions to patients?
Their answers are subjective (a.k.a subjective appraisal) thus they may have poor vision in one eye but may not have noticed because its in their ‘non dominant’ eye.
If a patient had a problem with intermediate vision by asking what they do at this distance what can you determine?
You can determine how to prescribe them according to what would best suit what they do at this vision and how regularly (e.g. lifestyle and ocupation).
Depending on this you would either prescribe
Bifocals
Varifocals
Or two separate glasses - one for near vision and one for distance vision.
After asking introductory questions and vision related questions, what questions will you ask next?
Probing questions- a question where you are asking about a particular thing e.g:
• Any problems with: • Flashes of light • Floaters • Why ask? • Retinal detachment • Associated with high myopia
Why ask probing questions such as whether they see flashes of light or floaters?
You are looking to see if they have any conditions wrong with their eye.
For example flashes of light and floaters may be indications of retinal detachment - (which is associated with high myopes).
When asking about things such as floaters you may need to explain to your patient what these are- how would you describe this?
Dark small shadowy shapes that cloud your vision (best seen against a bright background.
What are you looking for in regards to floaters?
Small number of floaters is normal.
You are looking to record if there is any change in size, shape or frequency of floaters.
If a patient answers yes to any question regarding visual problems then how do we follow up?
FLOADS.
We ask (and note) the following:
F-Frequency (e.g. how often does this occur? )
L- Location (e.g. which eye? what distance?)
O- Onset - (e.g. when did it start?)
A- Association - ( Does it happen when wearing glasses or without?)
D- Duration ( How long does it last?)
S-Severity (e.g. how severe is it?)
Why ask probing questions to do with headaches and double vision?
To prompt checking for:
Binocular Vision problems
Tumour
Vascular problems
If you have confirmed double vision what should be the next line of questioning in regards to this diplopia ( after FLOADS has already been done)?
Is it Vertical or horizontal? • Monocular or binocular? Sudden onset? • Associated with any position of gaze? • Constant or intermittent (phoria decompensating)?
What examples of questions to we ask in regards to ocular history?
Whether there is any history of:
• Squint (strabismus)
• Lazy eye (amblyopia)
• Ever had treatment at the hospital eye service
• Ever worn glasses/CLs
• If they have worn contact lenses you need to check when their last after care was - ( should be six months)
Why do we ask ocular history questions?
We want to know whether we should be expecting any problems due to ocular history.
You also want to ask so you can know about any previous tendencies for things such as conjunctivitis.
What examples of questions should you be asking in regards to family history?
- Whether there is any history of:
- Glaucoma
- Diabetes
- Hypertension
- AMD
- Any other eye disease
Why do we ask about family history?
• Certain diseases more likely with certain family
histories e.g:
• 10 – 50% of POAG (Primary Open Angle Glaucoma) patients report a
family history
• Sibling with POAG, then 4X more likely
• Parent with POAG, 2x as likely
Why ask about general health?
Poor general health may be
associated with ocular
manifestations
What is an example of a health condition that is associated with an eye condition?
E.g. Ankylosing spondylitis ( a type of arthritis) is associated with uveitis.
Why do we ask about medication?
All medication has side effects - some of them affect the eye.
What do you do if a patient doesn’t know the name of a drug?
Ask them what it is for
Why ask about allergies?
Some allergies are associated with certain eye
conditions
• E.g hayfever, asthma, eczema are
associated with Keratoconus (KC)
What is an important lifestyle question to ask adults?
Whether they are a driver and whether they wear glasses to drive.
What are the driving standards for vision?
The patient must be able to read a letter 79mm high at a distance of 20m AND have a VA of at least 6/12
(0.5) binocularly!
What lifestyle and occupational questions may we ask and why?
What the patients occupation is- this lets us know if perhaps the patient needs to be prescribed safety specs. Some jobs have visual standards that must be met.
Hobbies
Whether a patient is using a Visual Display Terminal (VDT) basically a screen of any type.
In regards to a Visual display terminal (VDT) what must you follow up and ask?
How many :
- Hours per day it is used
- How many Days per week it is used
At what Viewing distance is it used?
What advice do we offer to people that use VDTs a lot?
Remind them to always keep blinking as VDTs reduce blink rate- as a result eyes get dry. This makes eyes feel sore and dry.
The fact that when something is straight on you have reduced eyelid coverage. When you read ur eyelid covers more of your eye leading to less dryness.
Remind them that the employee is entitled to free eye tests from the employer if they would like them.
What is asthenopia?
A broad term that covers the following terms:
- sore eyes
- tired eyes
- eyes pulling
- visual discomfort
- (essentially eye fatigue symptoms)
Why do we ask about VDTs?
To know what advice to offer
What question should you always finish history and symptoms with and why?
‘Is there anything else I should know about your eyes?’
We ask this question to cover ourselves in litigation and in case you forgot to ask something.
If you don’t record a response what is assumed?
That you didn’t ask the question- so always record responses!
What are the consequences of poor litigation?
Can result in you being banned from practising.
