History and Symptoms 24-25 S PDF

Attendance code: Attendance code:  Attendance code: Group question OPT505 Lecture 2: History & Symptoms Ellie Livings  Attendance code: Intended Learning Outcomes By the end of the session you should be able to… Critic...

Attendance code: Attendance code:  Attendance code: Group question OPT505 Lecture 2: History & Symptoms Ellie Livings  Attendance code: Intended Learning Outcomes By the end of the session you should be able to… Critically evaluate example history and symptoms interviews Conduct a history & symptoms interview and record it systematically and accurately  Attendance code: https://optical.org/media/u5laljcz/requirements_for_approved_qualifications_in_optometry_and_dis pensing_optics_pdf-8.pdf GOC LO aligned to OPT505 relevant to H&S: O3.5a(i) 1. Person centred Care 2. Communication 3. Clinical practice Takes a relevant history from individual patients and any 4. Ethics & Standards other appropriate person involved in their care (relatives/carers and others). Interprets the results of history-taking and the examination of the refractive and ocular motor status and ocular health of individual patients to inform clinical decision-making and care management plans. Records all aspects of the consultation, the findings of all tests and relevant communications with patients, their carers and colleagues, ensuring that records are accurate, legible, dated, signed, concise, contemporaneous and securely stored.  Attendance code: ‘’Always listen to the patient, they might be telling you the diagnosis’’ Sir William Osler 1849-1919  Attendance code: Why? History and symptoms is really an exercise in detective work. It is the first step in determining the problem and formulating a range of investigations and management A large amount of the time, you will be able to make a diagnosis based on the history alone You are also building rapport with the patient GOC person centred care  Attendance code: What is the How do we How do we What are the How do the Do we need problem? manage… communicate significant problem and more this to the findings? the findings information? patient? link? What was Ocular Are there The vision? their chief health any other complaint? Who is your Do they tests we patient link? would like to do? Dispensing Refraction The health? needs OMB How might The recall? Health needs Do your Why have other findings they come information support the in? aid our What is symptoms? Any other diagnosis? Referral? normal? information  Attendance code: Rapport ‘’A good understanding of someone and an ability to communicate with them well’’ (Cambridge dictionary online) Confidence Body language Manner of speech  Attendance code: Profile of px Age Sex/race/religion/culture Occupation Hobbies Driver? Smoker?  Attendance code: Categories of required information: General information/ px profile Occupation, hobbies & driving Reason for visit (RFV) / presenting symptom Current visual correction if any, (including cls & refractive surgery) Satisfaction with unaided vision/current correction Symptoms (Sx): HAs, diplopia, flashes and floaters, pain/itchy General health (GH) Medication/allergies Ocular history (OH) Family history (FH) ocular and medical  Attendance code: Open questions non-specific and allow almost any response from the patient: ‘’Could you tell me about your vision?’’ it may take too long to get the information you need Closed questions can follow on to elicit specific information: ‘’What time of day do you get the headaches?’’ Also questions with response: yes/no. But can miss out on important information because your questions don’t fit with what your patient wants to tell you Leading questions Asking questions based on your own assumptions, which lead px to an answer you expect. (Not good for H&S) ‘’The headaches are worse in front of the computer, right?’’  Attendance code: Group Question feedback: H&S Order 1. Ask all about them 3. Anything else? Their health Their meds/allergies Their Ocular history Their current situation/problems/worries 2. Ask all about their family RELEVANT family health RELEVANT ocular history  Attendance code: Don’t Ask Ask Instead Follow up Were you patched as a child? Did you have to see the eye hospital as a Did they make you wear an eye child? patch? Give you exercises? How is your ocular health? Do you have any concerns about your eyes Have you ever injured your eyes or at the moment? been to eye hospital? Have you had any eye issues in the past How many hours a day do you spend on Do you spend much time on a screen? Do you use a PC, or a laptop/ipad? a VDU? What is your occupation? Are you working at the moment? What did you do before you retired? Is that mainly in an office setting? Does that involve much close work? What is your reason for visit? We haven’t seen you before…. Establish px’s status quo We saw you 2 years ago and you got new  Attendance code: How to record Record positive and negative Px responses: From legal viewpoint, no recorded response means question not asked Use only universally accepted abbreviations (CoO website) Records must be contemporaneous Px record is CONFIDENTIAL. (GDPR) CoO advice on record keeping on their website  Attendance code: Good Example Last EE: 08/22. Wearing varis f/t from then. Happy 𝑐. Cls used for weekends: DD monovision, last CL AC 1year, no probs. C/O vision a bit worse for reading, dv is ok. Drives 𝑐 rx: no probs. Px works in admin, vdu++ and paperwork. Sometimes eyestrain if tired. No/ha/dip/flashes/new floaters. (Longterm, stable floaters in RE. Aware flashes/floaters advice) Hobbies: reading, photography Non-smoker POH: none, no hes, no cl probs PGH: T2 diabetic, good control. Last DRS 2/12 →all ok, annual review Meds: metformin, amlodipine, simvastatin FH: FHG-dad @55, tx c drops.  Attendance code: Presenting complaint/RFV There may not be one…it may be routine-maybe the practice recalled them Could start with a summary: ‘’We saw you here 2 years ago and made up some new varifocals. Are those the ones you have on now? How are you getting on with them?’’ ‘’We haven’t seen you here before, roughly when was your last test?’’ Start with a fairly open question: Do you have any concerns about your vision today? The presenting complaint may not end up being the thing you want to investigate. You may notice something that needs looking at e.g unequal pupils, which the px has not. Be observant. Important for the px to feel heard. Assess the current situation Attendance code: Glasses: How many pairs? What type: Varis, SV, BFS? When are they used? Glasses How old are they? Condition? Getting on with them? Are they comfy/do they fit Happy with vision for TV/distance? What about driving? Unaided Happy can see to read? OK on the computer? Struggling to focus/getting eyestrain? Need sunglasses? DIY/special task requirements  Attendance code: What if my patient is a contact lens wearer? What type of contact lenses do they wear? How often do they wear their contact lenses? Do they have a pair of spectacles? When was their last CL aftercare appointment?  Attendance code: Patient Ocular Health: POH Start general, then follow up with specifics. Do you have any They don’t always know/remember/think it’s relevant problems with your If they answer yes, follow-up Q to get more info. E.g. yes I have AMD: How long, have you had any tx? eyes? If they wear cls, ask about them specifically Have you had any If there was an issue, e.g. HES as child. What can they remember? issues with your Were they patched, did they have surgery? Glasses? If they have an obvious facial scar, you can ask about it (gently) eyes in the past, maybe as a child? Have you ever seen Are they still under hospital? What was said? What tests did they do? the hospital about Especially useful if they were referred in the past, but you’re not your eyes sure why.  Attendance code: Patient General Health: PGH Try to be specific. List actual medication Do you take any They don’t always know/remember. Do your best. Record: ‘not known’ If you know they have a condition, e.g. diabetes, prompt them: Is that medication? diet controlled? Do you take medication. You can suggest names, ‘metformin?’ Do you have any Open question first, then ‘any ongoing health problems?’ You can ask, ‘any diabetes/stroke’ problems with Especially useful if you have pre-screening and you see something. your health? If they say a condition you don’t know, ask about it/Google it Do you have any Write what they are, or record ‘none’ allergies?  Attendance code: What if my patient is diabetic? Type of diabetes (IDDM or NIDDM) Onset? Control? When was their last diabetic retinal screening (DRS)? At their last DRS, were any abnormalities found? When is their next one scheduled? Any previous diabetic retinopathy/TX  Attendance code: What if my px has glaucoma? How long have they had it? What treatment? Any issues with their drops (compliance) Are they in a monitoring scheme? When were they last seen? NB: Do not necessarily need to perform perimetry if they are already monitored. May be useful if new px for a baseline, or to inform management.  Attendance code: Family Health: FH Are there any Start general, then follow up with specifics. They don’t always know/remember/think it’s relevant problems with eyes If they answer yes, follow-up Q to get more info. E.g. yes I have in your family? glaucoma: How long, are you in a monitoring scheme? Tx? Is there any Who? Approx. age of diagnosis? Type/tx? glaucoma in your If they are in a high risk group, you can ask: ‘what about anyone else: uncles, aunties etc?’ family as far as you Lots people get glaucoma and cataracts confused know?? Have you ever seen Are they still under hospital? What was said? the hospital about Especially useful if they were referred in the past, but you’re not your eyes sure why.  Attendance code: Symptoms Patients come in because they would like you to solve a problem. You must address their particular problem, or they will not realise you have done your job! When you finish the consultation, you must directly address the chief complaint. Even if your results have taken you elsewhere, patients want to hear about their reason for visit or any consulting complaint first Then address any other issues that have arisen  Attendance code: So you get a symptom: Questions Differential Clinical/refractive tests symptom Management diagnosis LOFTSEA  Attendance code: L Location But…… try to have O Onset a conversation F Frequency and occurrence T Type and severity S Self-treatment and its effectiveness E Effect on patient A Associated or secondary symptoms/factors Ask logical follow-on questions.  Attendance code: L Location Frontal headaches O Onset Started last few months F Frequency and occurrence Every day when reading T Type and severity Dull ache, 3-4/10 pain scale S Self treatment and its effectiveness Better if taking paracetamol E Effect on patient Makes them tired A Associated or secondary symptoms/factors Eyes feel tired and sore  Let’s play a game……. Attendance code: What animal am I? You can ask me yes/no questions to find out What animal am I? Attendance code: I am a small, nocturnal mammal, native to the British Isles. I hibernate in the winter and my diet is snails, worms and beetles.………  General Tips: Attendance code: There is a person attached to the pair of eyes. There may be other medical issues/factors to consider. (Px also forget this.) px: ‘I have a digestive problem.’ Px don’t know what is relevant to your history. You: ‘’ok, what kind of problem? Is there a name /diagnosis for it? Are you seeing a doctor?’’ You’re not being nosy It might be indigestion, it might be a condition like ulcerative Don’t be afraid to ask questions ‘outside of colitis which can have systemic inflammatory repurcussions such as uveitis. optometry’ Try not to spend ages writing in silence  Damage to rapport Attendance code: -Offending px (wrong name/pronoun etc) Problems -Giving a bad impression -Running late -Showing lack of confidence Not ‘driving’ the conversation -Allowing px to ‘run away’ with the conversation -H&S taking to long -No logical flow to H&S Pitching your level incorrectly - Appearing condescending - Using complicated vocabulary/jargon - Making jokes which land wrong Getting confused - Too many symptoms reported - Loosing track of line of questioning - Focussing on insignificant issue  Be prepared Attendance code: Take the time to read the notes/record Smile Solutions Introduce yourself Thank them for waiting Stay in control -It’s your testing room -Direct them to sit down before they start talking -Politely re-direct the conversation Judge your audience Use professional but friendly language Avoid jargon Use a word, then explain it e.g. Cornea, that’s the clear area at the front of your eye. Be logical/Have a plan Follow each symptom to it’s logical end Go back and clarify if you’re not sure Underline/highlight key symptoms  Attendance code: *  Attendance code: Headaches (HA) We need to differentiate…….. Primary Secondary HA is the primary HA is the secondary problem problem HA itself needs Underlying pathology treatment needs treatment Attendance code: Diagnosis based on clinical features Other sub-categories Migraines may be with/without aura Visual Migraine/aura Attendance code: Often a pre-cursor to a full migraine Typical description: Gradual onset of jagged lines, kaleidoscope, waterfall, blurry area Occur as retinal blood supply reduces with vessel attenuation Tend to follow pattern of retinal vascular supply Duration 10-20 mins, can be up to 1 hour May be accompanied by nausea Not always accompanied with HA Don’t assume it’s a visual migraine! Change in usual pattern Change in frequency/severity Accompanied with new symptoms Have they had it before? What’s their blood pressure like? Are they actually getting Amaurosis Fugax? (Transient visual loss: greying/blacking out of vision)  Attendance code: Systemic illness (fever) Intracranial stroke issues 2ndry Trauma HA stress Ocular Hormonal issues  Attendance code: The International Classification of Headache Disorders https://ichd-3.org/ Part II: The Secondary Headaches 11. Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures 11.3. Headache attributed to disorder of eyes 11.3.1. Headache attributed to acute glaucoma Ocular HAs that 11.3.2. Headache attributed to refractive errors optometrists can manage 11.3.3. Headache attributed to heterophoria or heterotropia (latent or manifest squint) 11.3.4. Headache attributed to ocular inflammatory disorder  Attendance code: https://practicalneurology.com/articles/2020-may/diagnosing-secondary-headaches  Attendance code: Is my HA caused by a brain tumour? Brain tumours are relatively uncommon: Other red flags for possible brain tumor The incidence of malignant brain tumour in the UK is 8.1 per 100,000 for men and 5.3 per 100,000 for women. HA with abnormal neurological findings https://assets.publishing.service.gov.uk/media/5a7d69dce5274a02dcdf4609/brain_tumo Behavioural changes ur.pdf Very severe HA, projectile vomiting HA as the primary symptom at presentation is unusual HA with history of cancer elsewhere Visual field loss (see lecture on field) New-onset epilepsy is much more likely to predict brain tumours than isolated headache: New diplopia Positive predictive values against a background risk of 0.013% were: Unexplained blurred vision new-onset seizure, 1.2% (95% confidence interval [CI] = 1.0 to 1.4); headache, 0.09% (95% CI = 0.08 to 0.10); Disorders of eye movements proptosis Hamilton W, Kernick D. Clinical features of primary brain tumours: a case-control study using electronic primary care records. Br J Gen Pract. 2007 Sep;57(542):695-9 Colour vision changes Optic nerve changes ( swelling, atrophy) Pupil changes (RAPD)  Attendance code: What do you need to do? Rule out any ocular causes for symptoms If ocular symptoms found manage accordingly If not, further investigations as required Refer appropriately  Attendance code: Management of headaches OCULAR NON-OCULAR Consider all your findings and If not ocular write a referral manage appropriately. letter or report that summarises Correct any significant refractive your consultation and ask px to change or binocular imbalance. see GP with a copy of that summary. Advise on ‘visual hygiene’! For chronic recurrent H/A, or See:CoO, Clinical Management migraine, px should keep a diary Guidelines to take with them to the GP. EMERGENCY REFERRAL: Acute closed-angle glaucoma, anterior uveitis, GCA, papiloedema  Attendance code: Summary H&S is your first opportunity to gain insight and rapport A good history relies on rapport and trust as well as the questions asked Use a template, but make it a conversation Implement a sensible flow of questions  Attendance code: Resources H&S article http://assets.markallengroup.com/article-images/image-library/147/uploads/importedimages/routine-eye- exam-pdf.pdf Brain tumor article https://www.aop.org.uk/ot/cpd/2018/07/11/keeping-an-eye-out-for-the-signs-and-symptoms-of-brain- tumours/article Headaches: https://www.ichd-3.org/ https://practicalneurology.com/articles/2020-may/diagnosing-secondary-headaches NICE Guidance https://www.nice.org.uk/guidance/cg150/chapter/Recommendations#assessment  Attendance code: Background Learning Develop a H&S question order/template to follow in routine exams Look at the record cards we use (lab books/Moodle) practise writing a history in the box Think about how you will record ‘normal’ answers Practise LOFTSEA on some common pathologies and their likely presentations Read about headaches and their classification Read CH 2 of Elliott’s Primary Eye Care Attendance code: Attendance code: