Case History PDF

CASE HISTORY Dr. Ariette Acevedo Rodríguez, O.D. PPO1 ”LISTEN TO THE PATIENT, HE IS TELLING YOU THE DIAGNOSIS.” -SIR WILLIAM OSLER Case History ■ This is the first and most important aspect of the examination ■ Helps us understand: – Why the patient is seeking care – Prioritize testing – De...

CASE HISTORY Dr. Ariette Acevedo Rodríguez, O.D. PPO1 ”LISTEN TO THE PATIENT, HE IS TELLING YOU THE DIAGNOSIS.” -SIR WILLIAM OSLER Case History ■ This is the first and most important aspect of the examination ■ Helps us understand: – Why the patient is seeking care – Prioritize testing – Determine the cause of the patient complaint ■ A good case history will give you the diagnosis – You then proceed to perform test to corroborate your diagnosis Case History ■ You need to know that the complaints could be caused by a given condition – Working diagnosis vs differential diagnosis ■ Example: – Burning sensation ■ Dry eyes vs Anterior Basement Membrane Dystrophy (ABMD) – Blurred vision at distance ■ Myopia vs Hyperopia vs Astigmatism – Progressive painless blurred vision at distance and near ■ Keratoconus vs Progressive Myopia Case History It is important that you: Create a bond with your patient Observe Listen Do a complete case history with proper documentation Always keep in mind that case history never ends Document CC and Case History Identify which tests to perform Perform Tests Interpretation and Analysis of Results Definite Diagnosis Case History General Observation ■ Very important to take note of your patient – Start observing from the waiting area ■ Observe: – Gait – Head position – Facial asymmetry – Skin color – Speech – General Appearance Elements of Case History Chief Complaint (CC) and History of Present Illness (HPI) Visual and Ocular History Medical History Medications History of Hypersensitivity/Allergies Social History (Adults)/Developmental History (Children) Vocational/Recreational Requirements Family Medical and Ocular History Demographic Data ■ Correct first and last name – Hispanic use a last name and surname. Avoid mistakes when addressing the patient – Dr. Ariette Acevedo Rodríguez, Dr. Acevedo, not Dr. Rodriguez – If you are unsure ask to avoid mistakes ■ DOB, age, gender ■ Address ■ Home and work phone number ■ Occupation: computer usage, monitor(s) height and distance, etc.… – If student ask about school grades, grades and modality. Case History ■ Create a bond – First opportunity to create a bond – Introduce yourself, greet them in a respectful manner – This is crucial in developing a good patient-doctor relationship – Building rapport and respect Chief Complaint ■ The reason this patient is seeking health care today. – Also known as History of Present Illness (HPI) ■ It is important you invite the patient to tell a story ■ Use open ended questions ■ Few patients come in for routine eye exams – Look for that reason why they came to see you ■ Follow the patient’s lead – Use verbal and non-verbal cues ■ Do not intervene too early or ask questions prematurely ■ Listen actively and use continuers – Ex: continue, go on, ya veo, entiendo, I see, uh huh. Chief Complaint ■ Ask open-ended questions at the early part of the case history ■ To investigate a particular problem or symptom, use a broad to specific approach ■ Other types of questions used during the examination: – Closed questions – Leading questions – Direct questions – Indirect questions Types of Questions ■ Closed questions gives the choice of a well-defined answer. – Is the complaint worse in the AM, PM, reading, computer use? ■ Leading questions: wording is suggestive of a reply. – Are your eyes burning when you read or as the day goes by? ■ Direct questions: The information is posed in the wording. – Do you see blurry at distance? ■ Indirect questions: Information to be gained is not in the wording but leads to disclose the desired information. – Suspected cataracts: Does your vision change with different levels of illumination? Case History ■ Be an active listener and adopt a manner that conveys this attitude. ■ Ask logical questions that may give you clues and guide your diagnosis. – Think ahead several questions – Do not dwell on questions or answers that are not being productive. – Avoid being repetitive once a questions has been answered. 3 questions you must ask yourself… 1. Does the patient have a problem? 2. What is the specific problem? 3. What is or will be the effect of the problem on the patient’s performance or physical status? Case History ■ History must be complete – Quote what the patient says and then document it – Legal protection (be accurate and document well) ■ If there are more than 1 complaints, ask the patient which is the most concerning one – This one is considered the Chief Complaint – Everything else is considered secondary complaints ■ Expand and clarify the patient’s story (HPI) – Elaborate on symptoms: context, associations and chronology. ■ Pursue: FLORIDA, OLD CART or OPQRST for the history of the complaint. Mnemonics for HPI ■ FLORIDA – ■ OLD CARTS – ■ Frequency, Location, Onset, Relief/alleviating or aggravating factors, Intensity, Duration, Associated factors Onset, Location, Duration, Character, Aggravating/Alleviating factors, Radiation, Timing, Severity OPQRST – Onset, Palliating/Provocation factors, Quality, Radiation/Region, Severity, Timing Documentation ■ Remember to quote the patient and then document HPI with FLORIDA ■ Frequency: How often does this occur? – Everyday, once a month, after school, at work, on vacation, in the morning (AM) or at night (PM) ■ Location: Where is the problem located? – OD/OS/OU ■ Onset: When did the problem begin? – Hours, days, weeks, months, years ■ Relief/Aggravation: What seems to make it better? What seems to make it worse? – Stopping visual task, rest, drops, medications – Reading, computer usage, dust, allergies Documentation ■ Intensity: How would you grade the severity of the problem? Intensity or quality – Intensity: Mild, moderate, severe, scale 1-10, painless, painful – Quality: Is it progressive or non-progressive ■ Duration: How long does the problem (symptoms) last? – All the time, few seconds, minutes, hours, days ■ Associated factors: What other symptoms do you experience, or do you relate the problem to some associated factors? – Stress, loss of coordination, elevated blood glucose, foreign body sensation ■ 15 y/o HF patient brought in by parents complains of blurry vision. ■ CC: Blurred vision ■ HPI: Example – F: everyday at distance and near – L: OU, OD>OS – O: for 1 month ago, getting worse – R: squinting – I: moderate, painless – D: all day – A: getting worse along with headaches (HA) ■ 15 y/o HF complains of progressive painless blurred vision OD>OS for 1 month ago, that improves by squinting and is associated with headaches. ■ Other complaints: Itching→ FLORIDA again ■ Do not assume the associated factor is another complaint. Documentation (SPANISH) ■ F: ¿Con que frecuencia ocurre? ■ L: ¿Donde (o cual)? ■ O: ¿Cuando comenzó? ■ R: ¿Que lo Alivia?¿Que lo empeora? ■ I: ¿Que tan severo es? ¿Esta progresando o empeorando? ■ D: ¿Cuanto tiempo dura esta queja? ■ A: ¿Relaciona esta queja con algo? Headaches ■ Need to be well evaluated, not all headaches are the same. – Primary vs. Secondary ■ P: Provocative-palliative ■ Q: Quality ■ R: Region ■ S: Severity ■ T: Timing ■ U: Unrelated aspects of the headache Case History ■ Ask regarding distance and near vision complaints with spectacles or contact lenses. ■ Learn the symptoms of ocular discomfort and the etiology of visual and ocular symptoms. – Assignment: Chapter 6 of Primary Care Optometry by Theodore Grosvenor Medical History ■ Systemic diseases may have ocular manifestations – Ex: DM, HTN, Autoimmune conditions ■ Systemic disease are usually related to a medication history – If patient reports no systemic condition but is taking Metformin and Insulin…DM ■ For females remember to ask for pregnancy and breastfeeding – According to age Review of Systems ■ ENT: ear, nose and throat ■ Hematologic ■ CV: cardiovascular ■ Neurologic ■ Endocrine ■ Psychiatric ■ GI: Gastrointestinal ■ Constitutional ■ GU: Genitourinary – Fever, weight loss, night sweats ■ Dermatological: skin, nails, hair ■ Respiratory ■ Immunological ■ Alertness and orientation – Especially in the geriatric population ■ Musculoskeletal Review of Systems ■ For each positive medical and ocular condition, the following need to be determined: – Date of diagnosis (when was this diagnosed) – Treatment (medication, surgery) – Dosage – Compliance (as ordered, if not why?, regular monitoring) – Last medical evaluation for the condition – Changes in medical treatment (on last evaluation) – Current status/outcome – Recommended follow up Medications ■ Medication, dosage and compliance ■ Include OTC, supplements, alternative medicine, medical cannabis ■ Adverse visual or ocular effects? – Learn ocular side effects or adverse reactions of medications ■ Ex: antihistamines, steroids, antimalaria, antidepressants, amphetamines PDR Allergies/Hypersensitivity ■ Important to ask this for every patient at every visit ■ Allergies to: – Medications – Food – Environmental pollutants – Dyes ■ What kind of reaction? ■ What relief/preventative measures? ■ NKDA Visual and Ocular History ■ LEE: Last eye exam – When was the LEE? – Age of current SRx – Comfort with actual prescription and frames – Age of current spectacle/contact lens prescription – What is it for? Distance, Near, Computer, All distance – Type of SRx (SV, Bifocals, Progressives (PALs)) – Are they seeking a second opinion? – Who was the previous doctor? Visual and Ocular History ■ Contact Lenses and Glasses History – Determine date of first SRx /CLRx – Prescribed for Distance, Near, Constant, Computer – Type lens: Single Vision (SV), Multifocal (MF), Daily, EW, DW, Progressives (PALs) – Hours worn/day (CL) – Disinfecting solutions (CL) – Wearing schedule (CL) – Last change of lens (CL) – Complications (CL): red eyes, ulcers, infections… – Discomfort or complaints Ocular History ■ Always ask if the patient has any of the – Tearing following complaints: – Sandy/gritty sensation in the eyes – Flashes of light – Trauma – Floaters ■ Ask the patient when was their last DFE – Halos – Double vision – Frequent or severe headaches – Eye pain – Redness Ocular History ■ Ask if the patient is under treatment for: – Glaucoma – Macular degeneration – Cataracts – Diabetic/Hypertensive retinopathy ■ For ocular disease document: – Date of diagnosis – Treatment (medication, surgery, therapy) – Dosage – Compliance – Last Evaluation – Changes in treatment – Current status/outcome – Recommended F/U History of Trauma ■ If a patient reports a history of trauma: – Describe the event – Location – When – Treatment – Lasting effects (sequelae) Ocular History ■ If the patient reports history of eye surgery – What type of surgery? – Surgeon? – When and where was it performed? – OD/OS/OU – When was it performed? Age? – Sequalae from it? ■ Visual training such as patching, visual therapy, ect… – For what? – When? – Outcome? Vocational and Recreational Needs ■ Computer Use: distance, height, hours. ■ Reading: distance, illuminating. ■ Distance vision ■ Recreational needs: – Scuba diving, swimming, snorkeling, hunting, shooting, woodworking, skiing, painting, fishing, golf. ■ This is important information to help you determine the final Rx and needs for special type of lenses. Social History ■ Remind the patient there is a confidentiality agreement – Patient can choose not to respond ■ Past or present history of – Tobacco – Alcohol – Illicit/Recreational drugs ■ If positive: – Type, frequency and amount Family Medical and Ocular History ■ Ask the patient for pertinent medical and ocular family history – Only from immediate family members ■ Important Hereditary Conditions: – Autosomal Dominant – Autosomal Recessive – X-linked Recessive Autosomal Dominant Inheritance ■ Congenital Ptosis ■ Corneal Dystrophies ■ Aniridia ■ Congenital Cataracts ■ Marfan’s Syndrome ■ Neurofibromatosis ■ Vitreoretinal dystrophy ■ Best’s Disease ■ Cone or cone-rod degeneration/dystrophy ■ Retinoblastoma ■ Optic nerve atrophy ■ Inherited blue-yellow defect color deficiencies ■ Choroidal dystrophies Autosomal Dominant Inheritance ■ Oculocutaneous Albinism ■ Stagardt’s Macular Dystrophy ■ Retinitis Pigmentosa ■ Choroidal dystrophies ■ Tay-Sachs disease X-Linked Recessive ■ Ocular Albinism ■ Inherited Red-Green color deficiencies ■ Juvenile Retinoschisis ■ Choroideremia ■ Leber’s Optic Atrophy ■ Fabry's Disease Complaints of Blurred Vision ■ After prolonged near work: presbyopia, hyperopia, astigmatism, accommodative infacility. ■ In reduced illumination: night myopia, retinitis pigmentosa, cortical cataracts. ■ In bright light: nuclear or posterior subcapsular cataracts. ■ Transient loss or obscuration of vision: disc edema, CRAO, temporal arteritis, carotid occlusive disease, migraine, MS ■ Unilateral blur vision: amblyopia, retinal pathology such as RD, macular hole, ARMD. Complaints of Eyestrain ■ Myopia ■ Hyperopia ■ Astigmatism ■ Binocular/Accommodative vision anomalies Complaints of Headaches ■ Due to eyestrain – Prescribe SRx or not? ■ Non-ocular headaches: – Migraines, HTN, temporal arteritis, muscular or tensional, cluster, nasal sinusitis, trigeminal neuralgia, cerebral aneurysm, intracranial mass. Most Common External Eye Symptoms ■ Itching and burning ■ Pain ■ Foreign body (FB) sensation ■ Light sensitivity (Photophobia) ■ Tearing ■ Dryness Common Visual Disturbances ■ Spots or floaters ■ Flashes of light ■ Temporary loss of vision ■ Curtain in front of the eyes ■ Distorted objects ■ Halos ■ Double vision Other Complaints ■ Deviating eyes ■ Protruding eye ■ Droopy eyelid ■ Unequal pupil sizes ■ Reading or learning problems – Most children are referred due to poor school performance, skipping lines, letter, incomplete school. – Important to ask during case history Differential Diagnosis-Hypothesis ■ According to the chief complaint and history you start generating your hypothesis (DDx) ■ Generating and testing different diagnostic hypotheses ■ Identifying the symptoms is important, what is the patient telling me? ■ Recognize patterns of diseases and generate differential diagnoses. ■ As you gain experience listening you will develop the skills of clinical reasoning – Therefore generating and testing diagnostic hypothesis will become easier and faster. Summary ■ At the end of the interview, always ask your patient if there is anything else you should know about his/her eyes, general health, family ocular and medical history. ■ It is important to summarize the reason for their visit: – “The reason for your visit today is__________ and you have concern about______.” ■ This will ensure you have understood what the patient is telling you and reinforces active listening. TERMS IN SPANISH Eye Structures ■ Eyelids: Párpados ■ Crystalline Lens: Lente Cristalino ■ Eyelashes: Pestañas ■ Vitreous: Vitreo ■ Lid margin: Márgen del Párpado ■ Retina: Retina ■ Conjunctiva: Conjunctiva ■ Optic Nerve: Nervio Óptico ■ Sclera: Esclera ■ Face: Cara ■ Episclera: Episclera ■ Forehead: Frente ■ Cornea: Cornea ■ Cheek: Mejilla, Cachetes ■ Anterior Chamber: Cámara Anterior ■ Chin: Mentón, Barbilla ■ Iris: Iris ■ Ears: Orejas Words Commonly Used ■ Eyeglasses: Espejuelos/Anteojos/Lentes ■ Contact Lenses: Lentes de Contacto ■ Multifocals: Multifocales ■ Single Vision: Vision Sencilla ■ Clearer: Aclarar, Mas Claro ■ Blurry: Borroso, Empañado, Nublado Most common verbs used during an Eye Exam… ■ Look: Vea, Mire ■ Burning: Arde/Ardor ■ Read: Lea ■ Itching: Pica/Picor ■ Cover: Cubra, Tape ■ Move: Mover ■ Take off/Uncover: Quite, Destape ■ Tell Me: Digame ■ Examine: Examinar ■ Put on: Poner ■ See: Ver ■ Pain: Dolor/Doler Eye Exam Instructions ■ Look straight forward: Mire al frente ■ Look at my ear: Mire a mi oreja ■ Do not move your eyes: No mueva sus ojos ■ Do not move your head: No mueva su cabeza ■ Place your forehead here: Ponga su frente aqui ■ Place your chin here: Ponga su barbilla aqui ■ Do not blink: No parpadee Eye Exam Instructions ■ Cover you right/left eye: Tape/cobra su ojo derecho/izquierdo ■ Tell me which one is better: dígame cúal es major ■ One, two or the same: Uno, dos o iguales ■ Tell me when it becomes blurry: dígame cuando este borroso ■ Tell me when you can read the letter/line: dígame cuando pueda leer la linea/las letras. ■ Tell me when you see them for the very first time: Dígame cuando las vea por primera vez. Eye Exam Instructions ■ Tell me when it becomes blurry, doiuble, then single again: Dígame cuando esten borrosas, dobles y sencillas. ■ Look up: Mire arriba ■ Look down: Mire abajo ■ Look to the left: Mire a la izquierda ■ Look to the right: Mire a la derecha Common Complaints ■ Blurred vision: vision borrosa, empañado ■ Eye strain: esforzar la vista ■ Tired eyes: ojos cansados ■ Headaches: dolor de cabeza ■ Double vision: visión doble ■ Words run together: palabras se juntan ■ Floaters: Flotadores ■ Flashes: relampagos de luz Common Complaints ■ Loss of vision: Perdida de vision o vista ■ Red eyes: ojos rojos ■ Itching: picor ■ Burning: ardor ■ Sticky eyelids: párpados pegados ■ Eye deviation: ojo desviado ■ Eye pain: dolor en los ojos ■ Pain behind the eyeball: Dolor detrás del ojo Common Complaints ■ Pain around the eyeball: dolor alrededor del ojo ■ Photophobia: fotofobia, molestia a la luz ■ Difficulties driving at night: problemas al manejar de noche ■ Difficulties Reading: problemas al leer Addressing the Patient ■ How are you (Mr, Mrs, Miss) LAST NAME? – ¿Como está (Señor, Señora, Señorita) Last Name ■ I am _______, optometry student. – Soy _________, estudiante de optometría. ■ Sit down, please. – Tome asiento, por favor. ■ Important to know: Usted vs Tu – “Tu” might be easier to pronounce, but if you are younger than the patient, it is considered disrespectful. Recommended: Watch and Read ■ https://www.youtube.com/watch?v=X1Mks6NJn1g ■ Bates Guide to Physical Examination and History Taking 2009 – Ch 1-3 Required Reading ■ Primary Eye Care – Theodore Grosvenor, 2006 – Ch 6- The Patient History ■ Clinical Procedures for Ocular Examination – Nancy Carlson, et al… – Ch 1