Download Making the Most out of Patient History

Making the Most out of
Patient History
Blair Lonsberry, MS, OD, MEd., FAAO
Professor of Optometry
Pacific University College of Optometry
[email protected]
Patient History
• “There are five routes to the medical
diagnosis-history, history, history, history and
the physical examination.”
» Tinsley R Harrison, MD
Patient History
• Patient history is the first and, many times, the
most important aspect of the optometric
exam
– allows for an “organized discussion” with the
patient
– informs the clinician why the patient sought
professional care
– directs the clinician in prioritizing the exam
Patient History
3 essential questions that must be answered:
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?
Patient History
3 maxims must be heeded:
1. The history never ends
2. The history should be complete
3. Listen carefully to the patient
Clinical Pearl
 Patients embellish the truth (Lie)
 some patients will only reveal all of the
necessary information to the doctor.
tell you a different complaint than
they tell the doctor
Clinical Pearl
– Patients know what they are supposed to
be “doing” and will “lie” that they are doing
that!
• E.g. ask a CL wearer “how often do you
sleep in your lenses” as opposed to “do
you sleep in your lenses?”
• E.g. ask patient what time of day do they
take their drops as opposed to how often
do they take their drops.
Important Information to Illicit:
Basic Demographic Data







Date
Time
Age
Sex/gender
Race
Occupation
Avocational needs
 Referral?
 Source of history (eg.
Patient, family, past
medical record)
 Reliability of data
source?
General Observation
 Remember to think of the patient as more than a pair of eyes
that walks in
 Want to make an overall general observation of the patient
including:
 Gait
 Head position
 Facial asymmetry
 Skin color
 Speech
 Appearance
Case History: Elements
A comprehensive case history contains the
following elements:
1.
2.
3.
4.
5.
6.
Chief complaint
Patient’s medical history
Medications and allergies
Visual and ocular history
Family eye and medical history
Vocational or recreational visual needs
Case History: Chief Complaint
• Chief Complaint:
– one or more symptoms/concerns for which patient is
seeking advice
– Primary reason the patient is seeking care
– Typically elicited by such questions as:
• “What seems to be the problem?”
• “What is the reason for this visit?”
• “What brings you to the office today?”
– To further expand the chief complaint, a series of questions
are asked to further expand on the complaint
• History of Present Illness or HPI
Case History: Chief Complaint
HPI: history of present illness.
– Typically require 4 modifiers for each HPI which
can include:
• Location
• Quality (e.g. sharp, dull, etc)
• Quantity or severity (how bad is it?)
• Timing (when? How long? How often?)
• Setting (environmental factors, activities)
• Factors making it better or worse
• Associated manifestations
Health History Review: Purpose
1. Px recognize and report symptoms. Clinicians
translate them into technical terms, group and
analyze them and make tentative hypotheses about
what causes are involved.
2. Symptoms guide the focus of the extent of the
physical examination and lab testing.
3. Talking with Px allows that person to feel that they
are understood and helps establish a therapeutic
relationship.
Case History: Medical History
 Importance of medical history:
 Is there a systemic disease that maybe
resulting in an ocular manifestation
 Systemic diseases also help identify possible
medications
Case History: Medical History
• Many patients don’t see the connection
between their systemic health and their eyes
so will not mention them
– Or if patient is currently medicated they don’t feel
the condition is worth mentioning
Case History: Medical History
• It is often necessary to ask patients about
their medical history and give examples of
conditions that you are interested in
– E.g. “Do you have any health problems such as
diabetes, hypertension, thyroid?”
Case History: Medications and
Allergies
 Numerous medications may manifest adverse
visual or ocular effects
 E.g.:
 Steroids: glaucoma, cataracts
 Allergy medications: dry eyes, CL problems
 Plaquenil (arthritis medication): cornea and retina
changes
Case History: Medications and
Allergies
• Patients often think that because they are
taking medications to control systemic
diseases that it means those conditions don’t
exist.
– Not until you ask about their medications do you
find out they have thyroid disease or hypertension
• Many female patients don’t consider birth
control pills as a medication
Case History: Medications and
Allergies
• Over the counter medications and
supplements are also usually not considered
by patients as “medications” because they are
not prescription.
• Important to find out if patient is allergic to
any medications and if they have allergies in
general to either foods or environmental
Case History: Visual and Ocular
History
 Visual history:




Time since last eye exam
Any recurring problems
How long has patient been wearing glasses
Any prior ocular disease, trauma, or surgery
Activities of Daily Living
• Need to understand the patient’s daily world in order
to assess if vision is impacting independence.
– things that may not be on your normal optometric “radar”.
• Dressing, grooming, cleaning, cooking, avocational
activities, driving?…
• Can the patient see details well enough to perform
these ADLs?
• Does visual field limitation impact these ADLs?
• Ultimately determines what other professional services
may be needed (Commission for the Blind, O&M
instruction, etc.)
Case History: Family Eye and Medical
History
• Family eye history:
– History of poor vision in the family may help
determine an accurate diagnosis
• “Has anyone in your family had any eye disease?”
– Certain eye conditions tend to “run in families”
such as:
•
•
•
•
glaucoma,
age related macular degeneration,
strabismus,
high refractive errors.
Case History: Family Eye and Medical
History
 Family Medical History:
 Certain systemic diseases have a genetic
predisposition
 Diabetes
 Hypertension
 Cholesterol
 Cancer
Case History: Vocational and
Recreational Needs
 Particularly important to ask patients if they
have and special needs at work or at home
 With the use of computers, many patients require
computer glasses in order to perform their job
 Certain recreational hobbies may require
special corrections or at a minimum eye
protection.
Case History: Psychosocial
• Psychosocial History:
– Alcohol?
– Smoking?
– Recreational drug use?
– STD’s?
General Appearance
 Level of consciousness
 When introducing yourself be
aware of the patient’s gross
level of consciousness?
 Is the patient awake, alert
and responsive?
 Personal Hygiene and Dress
 Is it appropriate for the
environment, temperature, age
and social status of the patient?
 Is the patient malodorous or
disheveled?
General Appearance
 Posture and Motor control
 What posture does patient assume while sitting in
the exam chair
 Are there any signs of involuntary motor activity
such as tremors
 E.g. damage to the cerebellum may produce a tremor
that usually worsens with movement of the affected
limb
General Appearance/Vital Signs
 Height, Weight and Build
 Note general body proportions and look for any
gross deformities
 Vital signs
 These include:
 Blood pressure
 Pulse
 Respiratory rate
 Temperature
Case Example
• 48 yr old white female presents with acute loss
of vision in her right eye and decreased vision
in her left
– She was scheduled 2 weeks previously for a diabetic eye
exam on a referral from her PCP but had fallen and was
unable to make that appointment
– She reports that her vision in her right eye seems to be
getting worse over the past several weeks.
– Was diagnosed with diabetes 1.5 years ago
• BS control has been erratic with range between 120-240
• Last A1C: 9.1
Blood Sugar
• Throughout a 24 hour period blood sugar typically
maintained between 70-145
– Diabetes is diagnosed with a fasting BS of > 126 or
an A1c value of > 6.5
• Hypoglycemia is typically defined as plasma glucose
70 or less
– patients typically become symptomatic of
hypoglycemia at 50 or less
Entrance Skills/Health Assessment
VA: OD: finger count
OS: 20/40
CVF: OD: unable to assess
OS: temporal
hemianopsia
Pupils: sluggish reactivity with a
2+ RAPD OD
SLE: corneal arcus noted, no
other significant findings
IOP: 16, 16 mmHG OD, OS
DFE: see photos
Note: not patient photos
http://content.lib.utah.edu/cdm4/item_
viewer.php?CISOROOT=/EHSLWFH&CISOPTR=159
Physical Presentation
• Upon entering the room I noted that her right hand
was twitching
– I asked her how long that had been going on and
she said about 2-3 weeks
– I asked her if she experienced headaches, to which
she said she had bad headaches that even woke her
up at night
Referral
• Contacted her PCP who reported that she had
examined the patient 3 weeks prior and had not
noted any of these findings
• Referred the patient for an immediate MRI
– wasn’t able to be scheduled until the next day
Imaging/Surgery Referral
• MRI revealed large mass in
her brain
– Patient was diagnosed with
a Craniopharyngioma
– She was referred for
immediate surgery
– Neurosurgeon reported that
she removed a tangerine
sized Craniopharyngioma
– was the largest tumor she
has ever removed
Note: not patient MRI
http://neurosurgery.ucla.edu/images/P
ituitary%20Program/Craniopharyngio
ma/Cranio_Sag_Preop_fullylabeled.jp
g
Our Patient
• Patient had a complete resection of the tumor in
addition to radiation therapy
• She developed several significant perioperative
complications:
– Leakage of CSF which resulted in her having to have a
shunt
• She subsequently developed an infection post surgically
– She is NLP in her right eye, but did regain 20/40 vision
in her left eye
• Retains a temporal hemianopsia OS
– Diabetes control became erratic and was put on several
hormone replacement medications
Neurological Screening: Cerebrum
• Frontal lobe
– Emotions, drive, affect,
self-awareness, and
responses related to
emotional states
– Motor cortex associated
with voluntary skeletal
movement and speech
formation (Broca)
Right vs Left Brain Injury
• So what happens if one side of the brain is injured?
– People who have an injury to the right side of
the brain "don't put things together" and fail to
process important information.
• As a result, they often develop a "denial
syndrome" and say "there's nothing wrong with
me.“
Right vs Left Brain Injury
• The left side of the brain deals more with language and
helps to analyze information given to the brain.
– If you injure the left side of the brain, you're aware that
things aren't working (the right hemisphere is doing its
job) but are unable to solve complex problems or do a
complex activity.
– People with left hemisphere injuries tend to be more
depressed, have more organizational problems, and have
problems using language.
Mental Status
 Primarily the function of the Frontal lobe







Consciousness
How we initiate activity in response to our environment
Judgments we make about what occurs in our daily life
Controls our emotional response, our expressive language
Assigns meaning to words, word association
Memory of habits and motor activities
“oriented to time and place”
Mini-Mental
• It is important to assess a patients “mental
status” and document that.
– Asking questions during case history such as a
patients address, their age, and even the date can
give you a patients “orientation to date and place”
– Assessing a patients general appearance can often
give an indication of mental status
Case History: Mental Status
 During case history:






Assess level of consciousness,
General appearance
Affect
Ability to pay attention
Understand what is being said
Speak
Case History: Mental Status
 Inability to take meds properly: dementia
 Attention slipping at work or business
 Grooming and personal hygiene may
deteriorate in:
 depression,
 schizophrenia and dementia
Epidemiology: Most common conditions that
cause visual impairment in adults
• ARMD (#1 in US/Canada/Europe)
• Cataracts (#1 in developing
nations)
• Glaucoma
• Diabetic retinopathy
• All the things that affect children
with low vision…these kids
generally grow to adults
The Effects of Eye Conditions
The Effects of Eye Conditions
A Corneal / Lens condition makes vision blurry and affects the ability to see
objects with poor contrast.
The Effects of Eye Conditions
A Retinal condition affects high and low contrast visual acuity, making
things blurry. Depending on the part of the retina affected, the central or
peripheral visual fields can also be affected.
The Effects of Eye Conditions
If a person has a central field loss, the size of the object may need to
be extremely large (i.e. large print) in order for it to be seen in the
person's peripheral visual field.
The Effects of Eye Conditions
The object needs to be smaller so that it can be seen
clearly in a person’s central field, if they have a peripheral
field loss.
The Atypical Patient
What is an atypical patient?
• Special populations,
– e.g. mentally challenged,
– physically challenged
• Trauma patients with resulting impaired
vision
• Elderly patients with reduced vision
• Emergent patients
Disability
• Disabilities can be:
– Congenital/acquired
– Stable/progressive
– Physical, cognitive, psychological, emotional,
sensory, perceptual or behavioral
Communication is usually the most challenging
aspect of dealing with patients with
disabilities!!!!
Classifications
 Impairment: limitation of basic function e.g.
decreased VA
 Disability: decreased ability to perform various task
as a result of an impairment (e.g. inability to drive,
write, watch TV)
 Handicap: limitations that people feel their
disability imposes on them. Perceived disadvantage
that occurs in response to a disability.
Clinical Pearl
 Many (including patient, doctor, family members)
focus on what patient cannot do instead of focusing
on the positive and build on the strengths of the
individual.
 Attitudes of the patient, family/friends and
healthcare providers have a significant impact on
how a patient manages their perceived disabilities.
Attitudes of Doctors Towards Patients’
with Disabilities
•
Doctors must consider their responses to patients with
disabilities. Five negative attitudes that result in negative
adversarial relationships include:
– Feeling sympathy, pity, fear, or hostility toward the child
or parents
– Demonstrating a feeling of hopelessness or hostility
toward the situation
– Over-identification with the patient or parents position,
reinforcing denial of the situation
– Viewing parental or patient’s observations as
untrustworthy or meaningless
– Viewing parents or patients as emotionally disturbed
Special Populations and Associated
Ocular Anomalies
•
•
•
•
•
•
Cerebral Palsy: strabismus, amblyopia, high refractive errors,
oculomotor dysfunction, visual-perception deficits.
Autism: typical visual behaviors (light gazing, staring at
objects), strabismus, refractive errors.
Mental retardation: high refractive errors, strabismus,
amblyopia, oculomotor dysfunction, visual-perception deficits.
Down’s syndrome: high refractive error, strabismus,
nystagmus, cataracts, keratoconus.
Developmentally disabled: high refractive errors, strabismus,
nystagmus, perceptual deficits.
Head injury: strabismus, binocular deficits, diplopia,
nystagmus, visual field deficits.
Clinical Pearl: Rapport with Patient and
Caregivers
•
•
•
Healthcare providers often overlook the patient for the
caregiver and inadvertently treat the patient with
disabilities as children or nonpersons.
It is crucial to develop a rapport with the caregiver as
they will be principle in ensuring compliance and
influencing the patient; BUT ultimately it is the patient
who is deserving of your attention and care. Do not
assume the patient has a limited cognitive ability
because of a physical disability.
Consider developing family-focused plans as opposed to
patient-focused.
Case History
 Case history (as with all patients) is a crucial
aspect of your exam.
 However, your case history may revolve around
the case worker or care giver.
 Crucial to determine if there have been any
behavioral changes that maybe associated
with the patients eyes, e.g. avoidance of
watching T.V., bumping into objects, excessive
rubbing of eyes.
Case History
•
•
Important to update any medication changes and
any other systemic conditions.
Do not assume that mentally or physically
challenged patients do not understand you or are
unable to respond to you.
– Try communication with patient first before
moving to care giver.
– Always identify the relationship of the person
with the patient, ie family member, care giver,
case worker etc.
Case History
•
•
•
Do not assume that mentally/physically
challenged patients do not have specific visual
needs, e.g. hobbies, work etc.
With trauma patients, it is crucial to obtain
what visual impact the trauma has had, and
what symptoms have arisen from the trauma.
A detailed history is crucial for any emergent
patient, e.g. what kind of trauma, when,
symptoms, medical assistance sought so far.
Thank You
[email protected]