Making the Most out of Patient History

Making the Most out of Patient History

Blair Lonsberry, MS, OD, MEd., FAAOProfessor of Optometry

Pacific University College of [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 ends2. The history should be complete3. 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. Chief complaint2. Patient’s medical history3. Medications and allergies4. Visual and ocular history5. Family eye and medical history6. 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 ComplaintHPI: 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


• 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


• 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


• 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


• 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, avocationalactivities, 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 DiabetesHypertension 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 photoshttp://content.lib.utah.edu/cdm4/item_viewer.php?CISOROOT=/EHSL-WFH&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 MRIhttp://neurosurgery.ucla.edu/images/Pituitary%20Program/Craniopharyngioma/Cranio_Sag_Preop_fullylabeled.jpg

http://neurosurgery.ucla.edu/images/Pituitary%20Program/Craniopharyngioma/Cranio_Sag_Preop_fullylabeled.jpg

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


A Corneal / Lens condition makes vision blurry and affects the ability to see objects with poor contrast.


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.


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 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 behavioralCommunication 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]

Documents

Making the Most out of Patient History