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Ophthalmology Pocket Guide > History Taking/Triage/Documentation > Flashcards

History Taking/Triage/Documentation Flashcards

1
Q

Greeting

A

Identifying/Introduce yourself
Explain your role in the exam
Identify person(s) accompanying the patient (HIPAA)

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2
Q

Chief Complaint

A

Purpose of visit recorded in the patient’s own words

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3
Q

History or present illness (HPI)

A 
Supporting Information for the chief complaint'
Physician referral
Symptoms
     Sudden or gradual
     How long have the symptoms been present 
     Has patient had these symptoms before 
     Severity
     Frequency
     Course-better, worse, no change
     Associated signs and symptoms
Previous treatment
     Medication
     Surgery
     Glasses change
     Treatment by any other providers
Review of systems:
     Respiratory systems (lungs)
     Cardiovascular systems (heart and blood vessels)
     Endocrine system (hormonal)
     Nervous System (neurological)
     Digestive and excretory system (gastrointestinal and urological)
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4
Q

Past ocular history

A 
Eye glasses-refraction stable
Contact lens wear
Any previous eye surgery
Any ocular trauma, or eye disease
Infections
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5
Q

Ocular Medications

A

Eye drops, ointments, or oral medications for eye condition
Dosage
Strength
Last taken
Compliance (patient follows the advice of the doctor, and takes the prescribed drugs in the quantities prescribed)

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6
Q

Past medical History

A 
Medical conditions-i.e., diabetes, hypertension, etc.
     Length of illness
     Duration of treatment
Hospitalizations
Trauma
Surgeries
Mental Status
Pediatrics
     Full term/premature
     Birth compliance
     Developmental History
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7
Q

Systematic medications

A 
Prescribed medications
     Dosage
     Strength
     Duration
     Compliance
Over the counter medications/suppliments
     Dosage 
     Strength
     Duration
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8
Q

Social and Vocational History

A 
Smoking
     How much
     Duration
Alcohol (ETOH)
     How much-e.g. socially
     Duration
     Abuse
Recreation drugs
     How much
     Duration
Employment/profession
Hobbies
Weight loss/weight gain
Marital Status/children
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9
Q

Family History

A

Ocular history

Systemic

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10
Q

Allergies

A

True allergies to medication(s) are hives or difficulty breathing.
Any other reaction is considered sensitivity and not a tru allergic reaction.
Ocular and systems medications (type of reaction)
Dyes
Contact lenses/solutions
Tape/latex
Seasonal
Environmental
Food

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11
Q

Scribe

A

Recording either in written form or electronically “verbatim” what the physician states while examining the patient.

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12
Q

Necessary documentation

A

A statement and signature of the ophthalmic technician stating that he/she recorded exactly what was stated by the physician and the physician’s name.

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13
Q

Complete

A

Statement and signature by the physician verifying that he/she indeed stated what was recorded and that the ophthalmic technician did record it

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14
Q

Telephone triage

A

Gather information

Determine the urgency of patient’s complaint

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15
Q

Proper triage is critical

A

An error in judgement may cause:
Pain and suffering
Loss of vision
Potential legal problems

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16
Q

Gathering information

A

It is important to be calm and reassuring when speaking to patients with urgent concerns:
Speak to the caller as though you are speaking face to face
When patients have an urgent concerns, they want to speak with someone who is concerned, reassuring and knowledgeable.
Be calm, but gather the needed information quickly and concisely
Listen carefully and document accurately
A patient with high anxiety needs reassurance even if the situation is not truly emergency

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17
Q

What information is needed?

Begin the triage process by recording patient’s answer to these questions:

A

What is the chief complaint?
Common urgent complaints may be blurred vision or loss of vision, eye pain, redness, discharge, light sensitivity or an acute injury.
Which eye is involved?
How did it happen? (for injuries)
When did the symptoms start?
Was the onset sudden or gradual?
Are the symptoms constant or intermittent?
Are the symptoms getting better, worse, or about the same?
Did you go to emergency room or your primary care physician before contacting our office?
have you ever had anything like this happen in the past?

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18
Q

Triage

A

prioritization of patient care (or victims during a disaster) based on illness/injury, severity, prognosis, and resource availability.

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19
Q

Emergent problems

A

True ocular emergencies-see as soon as possible

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20
Q

Urgent problems

A

Need same-day appointment

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21
Q

Priority Problems

A

Appointment within days

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22
Q

Routine problems

A

Routine appointments

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23
Q

Emergent problems-tru ocular emergencies (ask patient to come to office immediately)

A

Sudden loss of vision-painful
Sudden loss of vision-painless
Sudden loss of vision, painless with flashes, floaters
Penetrating injury
Chemical burns
Acute proptosis (bulging or protruding eyeballs) with loss of vision
Blunt trauma with sudden loss of vision and proptosis
Sudden loss of vision with headache
Sudden onset of diplopia with headache

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24
Q

Sudden loss of vision-painful

A

Red eye with severe pain, rainbow-colored halos, a cloudy cornea
Possible acute angle-closure glaucoma
Immediately measures to lower IOP
Definitive treatment with laser or surgery

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25
Q

Sudden loss of vision-painless

A

Sudden painless loss of part or all of visual field
Suspect vascular occlusion-central retinal artery, branch artery or central retinal vein
Check with doctor for possible therapy prior to arrival in office

26
Q

Sudden loss of vision, painless with flashes, floaters

A

Suspect retinal detachment
May see veil or curtain
Loss of field of vision

27
Q

Penetrating Injury

A

Potentially sight-threatening
Surgery required to restore structural integrity
Protect globe prior to surgery
Associated facial or orbital injuries
Often poor prognosis
Risk of infection
Multiple procedures may be required

28
Q

Chemical Burns

A

Treatment required prior to full history
Irrigate the eye
Suspect associated mechanical injury depending on mechanism of injury
Time is the important factor in outcome

29
Q

Acute proptosis (bulging or protruding eyeballs) with loss of vision

A

Accompanied by fever and malaise

Need to rule out orbital cellulitis

30
Q

Blunt trauma with sudden loss of vision and proptosis

A

Need to assess for retrobulbar hemorrhage

Needs urgent canthotomy/cantholysis to release orbital pressure

31
Q

Sudden loss of vision with headache

A

Associated with malaise, fever, weight loss, loss of appetite
Need to rule out temporal arteritis
Erythrocytes sedimentation rate, C-reactive protein, and platelet levels need to be assessed
High dose os steroids may need to be started to prevent further vision loss or contralateral loss.

32
Q

Sudden onset of diplopia with headache

A

Associated with ptosis and a ‘blown’ pupil

Need to assess for aneurysm compressing the oculomotor nerve

33
Q

Urgent problems-same day appointment

A 
New onset flashes and floaters
Blunt Trauma to the eye
Sudden onset of double vision
Red eye (may be minor problem or serious; many red eyes warrant a same-day appointment)
Protrusion of an eye
Contact lens problems
34
Q

New onset flashes and floaters

A

Suspect retinal detachment
Often benign vitreous detachment
Requires dilated exam

35
Q

Blunt Trauma to the eye

A

Vision may be difficult to assess
Orbital floor fracture (blowout fracture) may cause double vision
Occult rupture of globe
Detached or torn retina
Intraocular hemorrhage-hyphema or vitreous hemorrhage

36
Q

Sudden onset of double vision

A 
Patients may describe double vision but actually have ghost image
To determine true double vision, instruct patient to cover each eye; if diplopia resolves, the patient has true double vision, requiring immediate attention
True diplopia (often serious)
CVA, diabetes, thyroid disease, brain tumor, metastatic lesion, neurological problems, hypertension or trauma.
Ghost image can be addressed with priority appointment
Possible cataract, media opacity or uncorrected astigmatism.
37
Q

Red eye (may be minor problem or serious; many red eyes warrant a same-day appointment)

A

Red eyes accompanied by discharge, tearing, itching or swelling; suspect microbial conjunctivitis; keratitis or keratoconjunctivitis, allergies or dry eyes.
Redness with associated sharp, stabbing pain and light sensitivity; suspect corneal involvement; ulcers are urgent
Pain, photophobia, decreased vision and red ring surrounding the cornea; suspect iritis, often associated systemic problems
Bright red spot on conjunctiva with no associated symptoms; suspect subconjunctival hemorrhage; benign, but patients often require reassurance.

38
Q

Protrusion of an eye

A

One or both eyes
Painful or painless
Sometimes accompanied by double vision
Suspect thyroid disease, tumors or orbital pseudo tumor

39
Q

Contact lens problems

A

New onset of pain, redness, discharge, photophobia (very sensitive to it), poor vision or change of vision

40
Q

Priority problems-should be within days of their initial complaint

A 
Slow disease Progression
Gradual, painless decrease in vision
Lid problems
Lost or broken eyeglasses
Ocular Migraines and headaches
41
Q

Slow disease Progression

A

(Emergency” requests sometimes from patients with long-standing condition)
Symptoms may have worsened
Anxiety
Underlying problem requires attention
Delay of a day or two unlikely to affect the outcome

42
Q

Gradual, painless decrease in vision

A

Suspect cataract or macular degeneration
Chronic open-angle glaucoma can be priority appointments unless new pain, redness, severe headaches or seeing rainbows around lights

43
Q

Lid problems

A

lumps and bumps; often caused by styes, etc.
Associated blepharitis
rare malignant lesions

44
Q

Lost or broken eyeglasses

A

Patients unable to function

May need only limited appointment

45
Q

Ocular Migraines and headaches

A

Ocular migraines are not necessarily a true emergency
May be difficult to differentiate from retinal detachment
Headaches that are chronic can be routine or priority appointment

46
Q

Routine-make a routine appointment

A

Chronic problems that are slowly progressive:
Mild irritation or other problems that may resolve on their own
Some simply require patient instruction or a routine exam
Patients with long-standing floaters without flashes or changes in vision
Abnormal blinking
Dryness
Gradual changes in near or distance vision
Long-standing droopy eyelid
Small, yellowish raised bump on the white of the eye (pinguecula)
Glare with night driving

47
Q

When in doubt

A

Check with doctor for guidance
Err on side of safety
Schedule patient ASAP

48
Q

Gradual loss of vision

A

Ametropia (increase or change in refractive error)
Media opacitiesL mucus, cornea, aqueous, lens, vitreous
Receptor defect; Retina, optic nerve, chiasm, occipital cortex

49
Q

Sudden loss of vision lasting >1/2 hour

A 
Optic neuritis
Occlusion of central retinal A or V
Vitreous hemorrhage-often diabetic retinopathy
Retinal Detachment
Hysteria
50
Q

Sudden loss of vision lasting <1/2 hour

A

Amaurosis fugax: transient ischemic attack (elderly)

Ophthalmic migraine: Occurs in second and third decade (not limited to)

51
Q

Halo

A

Glaucoma and other causes of corneal edema
Cataracts or conjunctival secretions (infrequently)
Post laser vision correction (LASIK or PRK)

52
Q

Curtain

A

Retinal Detachment or hemorrhage
Amaurosis fugax
Ophthalmic migraine

53
Q

Flashes of light

A

Retinal: Vitreous traction or trauma to retina
Occipital: Migraine headache

54
Q

Nyctalopia (night blindness)

A

Retinitis pigments
Other degenerations of rods receptors
Vitamin A deficiency

55
Q

Spots

A

Muscae volitantes
Scotoma corresponding to defective area of retina
corneal foreign body

56
Q

Diplopia

A

Monocular, hysterical or due to light splitting from corneal (double vision) or lenticular opacity
Binocular: due to muscle imbalance oor paralysis; eliminated by occluding one eye

57
Q

Asthenopia (eye fatigue)

A

Phoria; fatigue of extra ocular muscle during attempt to maintain fusion
Hyperopia or presbyopia: fatigue of accommodative muscle
Other refractive errors; prolonged blur causes discomfort

58
Q

Ocular tenderness

A

Episcleritis, endophthalmitis
Markedly elevated intraocular pressure
Lid or orbital inflammation
Scleritis

59
Q

Photophobia

A 
Uveitis 
Albinotic and lightly pigmented eyes
Keratitis 
Conjunctivitis (infrequently)
Corneal abrasion
60
Q

Gritty Foreign-body sensation

A 
Conjunctivitis 
Ocular foreign body
Corneal Abrasion
Dry eye syndrome
Trichiasis
61
Q

Itching and burning

A

Conjunctivitis-especially allergic

Occurs with asthenia

Ophthalmology Pocket Guide (10 decks)

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