History Taking 1 - Week 1 Flashcards
In what order do we structure our patient history questioning/discussion?
Presenting Complaint (PC) Screening Questions Patient ocular history (POH) Family ocular history (FOH) General Health (GH) Visual Tasks (VT)
What should we consider as a starting point for Hx?
Demographic information, including:
-Name, Address, Contact No., Age, Occupation, Medicare/pension cards, Previous attendance (record cards), Often collected by reception
How do we identify the patient’s Presenting Complaint?
We ask the patient: “What has brought you in to see us today?” (or some variant thereof)
True or False: A patient can have multiple presenting complaints.
True
What should you first ask when you see a patient
Ask what has brought them in to see us today
What should you consider for a patient’s presenting complaint(s)?
- When first noticed
- Location of problem
- Frequency
- Severity
- Duration
- related to any tasks the patient does?
- relieving factors
- assoc. signs or symptoms
- progression of complaint
- idea of cause
Way to remember: “When I noticed the severity and frequency of my complaint, the duration of my assoc. signs and symptoms gave me an idea of the problems location. I am relieved.”
What does LOFTSEA stand for? And what is it used for?
Used to help remember what to check/ask for PCs L - Location/Laterally O - Onset F - Freq. T - Type/severity S - Self treatment and its effectivity E - Effect on patient A - Assoc, signs + symptoms
What does COLDER stand for? And what is it used for?
Used to help remember what to check/ask for PCs
C - Character (quality, severity and assoc, signs)
O - Onset
L - Location
D - Duration
E - Exacerbation
R - Relief
Yeah, Loftsea is way better
Once you have completed PCs, what next?
Ask Screening Questions
What Screening questions?
If they are not the presenting complaint, ask:
- How is your vision? (at dist, near, intermediate)
- find out if use any aids for these tasks
- sore eyes, red eyes (black dragon), itchy eyes
- see flashes/floaters
- headaches related to their eyes
- double vision
- dry watery eyes
What questions should you ask for Patient Oc. His. (POH)
most important:
- Previous visits? - when was last visit?
- Eye operations - have you had any? (are you Joey’s sister Serenity?)
- Eye injuries
Others:
- Eye infections
- 1st glasses - are these your first? when first?
- Previous practitioners?
- Turned lazy eye (mainly ask in children)
What comes after screening questions?
Patient ocular history (POH)
What comes after POH?
Family ocular history (FOH)
What should you ask for FOH?
- anyone in family with glaucoma (nerve damage due to high IOP)
- macular degen
- turned/lazy eye/patching (if child)
- anyone with a systemic condition like diabetes, hypertension, heart disease, high cholesterol
- high prescription (Rx) or blindness
What comes after FOH?
General medical health/medical history
What questions should you ask for General Health?
Start with open question: How is your general health?
- history of diabetes, high blood pressure, heart disease, cholesterol?
- on any medications?
- any allergies? Ocular or systemic
- GPs name and address, how often they see
What comes after general health?
Visual Tasks (VT)
What questions should you ask for Visual Tasks?
- driving –> and w/w/out glasses
- occupation
- hobbies –> esp those with unusual working distances
- computer/screen (VDU) hours
What comes after visual tasks?
Summary and then begin procedure
How should you address the patient?
Formally until otherwise said. I.e mr/ms/dr
What are important specific questions that you ask? (If something arises e.g yes to floaters etc)
- when first notice
- how long/duration
- nature of (e.g are floaters coloured or white)
- frequency
What questions should you ask if Px has headaches?
- Location? Frontal, temporal or occipital
- onset/duration (time and activity)
- frequency/severity scale: progression of pain
- medicine, dosage type: efficacy/side effect. Over the counter or prescribed?
- symptoms: any nausea or vomiting?
