V550 The History Questions Richard E. Meetz, OD, MS 2009
The Working Phase: <ul><li>Setting up the record </li></ul><ul><ul><li>Date and time </li></ul></ul><ul><ul><li>Demographi...
Date and Time <ul><li>The  full date  must be on every record! </li></ul><ul><ul><li>Month / day / year </li></ul></ul><ul...
Date and Time <ul><li>Time should appear: </li></ul><ul><ul><li>Early in the examination (start) </li></ul></ul><ul><ul><l...
Date and Time <ul><li>12 vs 24 hour clock?  </li></ul><ul><ul><li>Not critical as long as reader can tell morning from aft...
Demographics <ul><li>Name: Last Name, first name & middle initial </li></ul><ul><ul><li>Must be on every page of record! <...
What Questions to Ask? <ul><li>The series of questions and order will depend on the type of examination. </li></ul><ul><ul...
What Questions to Ask? <ul><li>Always keep in mind that there is a reason for every question we will ask. </li></ul><ul><l...
What Questions to Ask? <ul><li>The order needs to be logical! </li></ul><ul><ul><li>For both the clinician and the patient...
The Reason for Seeking Care <ul><li>The Reason for Visit (RFV) </li></ul><ul><ul><li>Can be for a vision complain (CC) </l...
The Reason for Seeking Care <ul><li>The Reason for Visit (RFV) </li></ul><ul><ul><li>“ The coverage of services rendered (...
The Reason for Seeking Care <ul><li>The Reason for Visit (RFV) </li></ul><ul><ul><li>Chief complain (CC) </li></ul></ul><u...
The Reason for Seeking Care <ul><li>The Reason for Visit (RFV) </li></ul><ul><ul><li>Routine exams that are not covered by...
The CMS <ul><li>The Centers for Medicare & Medicaid Services </li></ul><ul><ul><li>Federal agency responsible for manageme...
The Reason for Seeking Care <ul><li>Chief Complaint: CC </li></ul><ul><ul><li>Ask an open-ended question </li></ul></ul><u...
The Reason for Seeking Care <ul><li>Chief Complaint (cont’d) </li></ul><ul><ul><li>Record statement in the patient’s own w...
The Reason for Seeking Care <ul><li>History of present Illness: HPI </li></ul><ul><li>The goal of the HPI is to develop a ...
History of Present Illness (HPI) <ul><li>Location </li></ul><ul><li>Quality </li></ul><ul><li>Severity </li></ul><ul><li>D...
History of Present Illness (HPI) <ul><li>NOTE :  </li></ul><ul><li>You do not need to ask all 9 questions, only as many ne...
Most Common History Pitfall: <ul><li>Not fully questioning the patient about the HPI. </li></ul><ul><ul><li>Reasons : </li...
Most Common History Pitfall: <ul><li>By not understanding the CC, you will spend too much time doing unnecessary testing o...
2nd Most Common History Pitfall: <ul><li>Not recording enough details of the HPI to support the level of care. </li></ul><...
Most Common Missed Question: <ul><li>Which eye or both? </li></ul>
Recording the CC & HPI <ul><li>Recorded in short words and phrases </li></ul><ul><ul><li>Example: After the CC, Patient sa...
Recording the CC & HPI <ul><ul><li>You record : </li></ul></ul><ul><ul><li>CC: “blurred vision when driving”, late night o...
Recording the CC & HPI <ul><ul><li>If patient’s RFV has no CC, then hold off recording ‘routine’ until end. </li></ul></ul...
Hx mnemonics <ul><li>A mnemonic is a word or words that serve as a memory trigger for remembering steps or parts of  </li>...
TADD <ul><li>Used for F/U of all   2° Sx </li></ul><ul><ul><li>T ime of onset: 1 st  date  and  time of day </li></ul></ul...
Beyond TADD <ul><li>NOTE! </li></ul><ul><li>TADD is  only the bare minimum  f/u for any Sx. </li></ul><ul><li>You are not ...
Beyond TADD <ul><li>OPQRST </li></ul><ul><li>Is a mnemonic for a better set of symptom analysis questions; </li></ul><ul><...
OPQRST <ul><li>O= Onset </li></ul><ul><ul><li>Onset; when did it begin? </li></ul></ul><ul><ul><ul><li>Day, weeks, months ...
OPQRST <ul><li>P=  </li></ul><ul><ul><li>Provocative= What makes it worse? </li></ul></ul><ul><ul><li>Palliative = What ma...
OPQRST <ul><li>R= Region/Radiation </li></ul><ul><ul><li>Where does it occur? </li></ul></ul><ul><ul><li>Does it radiate? ...
OPQRST <ul><li>T= Timing  </li></ul><ul><ul><li>Time of day, AM or PM? </li></ul></ul><ul><ul><li>Gradual or abrupt? </li>...
OLD CARTS <ul><li>Is a mnemonic similar to OPQRST; </li></ul><ul><li>O= Onset </li></ul><ul><li>L= Location </li></ul><ul>...
Medical Charting <ul><li>Recording in the medical chart </li></ul><ul><li>In the busy medical office, there is a need for ...
Medical Charting <ul><li>Recording in the medical chart </li></ul><ul><li>“ Telegraphing” </li></ul><ul><ul><li>A techniqu...
Medical Charting <ul><li>“ Telegraphing” </li></ul><ul><li>Example: full wording  </li></ul><ul><li>The patient denies tha...
Medical Charting <ul><li>“ Telegraphing” </li></ul><ul><li>Example: telegraphed </li></ul><ul><li>Patient denies any drain...
Medical Charting <ul><li>Recording the Chief Complaint </li></ul><ul><li>The CC must be in the patients own words!  </li><...
Medical Charting <ul><li>Recording the Chief Complaint </li></ul><ul><li>Example: full wording </li></ul><ul><ul><li>Patie...
Medical Charting <ul><li>Recording the Chief Complaint </li></ul><ul><li>Bad Examples: </li></ul><ul><ul><ul><ul><li>( fro...
Medical Charting <ul><li>Recording the Chief Complaint </li></ul><ul><li>Bad Examples:Missing words? </li></ul><ul><ul><ul...
Medical Charting <ul><li>Recording the Chief Complaint </li></ul><ul><li>Bad Examples:Conflicts! </li></ul><ul><ul><ul><ul...
Symptomatology <ul><li>Is the art of recognizing the classical symptoms of diseases and disorders and how patients typical...
Common Refractive Sx <ul><li>1. Hyperopia  – “Far sighted” – not enough power or eye is too short.  Patient can accommodat...
Common Refractive Sx <ul><li>2.Myopia  – “Near sighted” – Too much power or eye is too long.  Eyes are focus for near. </l...
Common Refractive Sx <ul><li>3. Astigmate  – Warpage of cornea causing a slight blur or “double” image at all distances. <...
Common Refractive Sx <ul><li>4. Presbyopia  – Loss of near focus as part of normal aging.  Can occur with any of the above...
Common Binocular Sx <ul><li>5. Accommodative Dysfunction  – inability to hold clear near vision or a spasm of near focus i...
Common Binocular Sx <ul><li>Accommodative Dysfunction </li></ul><ul><ul><ul><li>Typically school age to mid 20’s </li></ul...
Common Binocular Sx <ul><li>6. Binocular Dysfunction/Vergence Dysfunction  – Extra ocular muscle’s inability to hold singl...
Common Binocular Sx <ul><li>Binocular Dysfunction/Vergence Dysfunction (cont’d ) </li></ul><ul><ul><ul><li>School age to 4...
Common Ocular Sx <ul><li>7. Optical Quality/ Optical Distortion   </li></ul><ul><ul><li>Loss of sharp optic transmission d...
Common Ocular Sx <ul><li>Optical Quality/Distortion (cont’d) </li></ul><ul><ul><ul><li>40 y.o. and up  </li></ul></ul></ul...
Common Ocular Sx <ul><li>8. Diplopia  – Symptoms of double vision, can be binocular (vergence or neurologic) or monocular ...
Common Ocular Sx <ul><li>Diplopia  (cont’d) </li></ul><ul><ul><ul><li>Any age, Sx clear-cut or vague </li></ul></ul></ul><...
Common Ocular Sx <ul><li>9. Photopsia  – Spontaneous flash or spark of light or slow flicking streaks or spectrums. </li><...
Common Ocular Sx <ul><li>Photopsia  (cont’d) </li></ul><ul><ul><ul><li>Any age (teens and up) </li></ul></ul></ul><ul><ul>...
Common Ocular Sx <ul><li>10. Ocular Discomfort  – Sx vary from asthenopia to compelling pain arising or localizing in the ...
Common Ocular Sx <ul><li>Ocular Discomfort (cont’d) </li></ul><ul><ul><li>Often with other S&S of redness, tearing, HAs, F...
Common Ocular Sx <ul><li>11. Red eyes  – Increased visibility of conjunctival vessels.  Sx range from a mild sting or irri...
Common Ocular Sx <ul><li>Red eyes  (cont’d) </li></ul><ul><ul><ul><li>Any age </li></ul></ul></ul><ul><ul><ul><li>Often wi...
Common Ocular Sx <ul><li>12. Halos or rays  – Reports of rings around light or streaks shooting out of lights at night. Du...
Common Ocular Sx <ul><li>Halos or rays (cont’d) </li></ul><ul><ul><ul><li>Contact lens wearers and  </li></ul></ul></ul><u...
Common Ocular Sx <ul><li>13. Photophobia  – Abnormal sensitivity to light.  </li></ul><ul><li>* Ocular pain with light. </...
Common Ocular Sx <ul><li>Photophobia (cont’d) </li></ul><ul><ul><ul><li>Any age, most often young, blue eyes (idiopathic) ...
Common Ocular Sx <ul><li>Photophobia (cont’d) </li></ul><ul><ul><li>Important F/U question for a Photophobia  patient </li...
Common Ocular Sx <ul><li>14. Vision Loss  – Diminution of vision in part or all of the visual field in one or both eyes.  ...
Common Ocular Sx <ul><li>Vision Loss (cont’d) </li></ul><ul><ul><ul><li>Older patients but can be teens and up </li></ul><...
Common Ocular Sx <ul><li>15. Headache  – Reports of pain discomfort around, top of, through, under the head.  See also abo...
<ul><li>Headache (cont’d) </li></ul><ul><ul><li>Assoc. with  many symptoms and etiologies </li></ul></ul><ul><ul><li>Sympt...
Back to the Hx: <ul><li>Demographics </li></ul><ul><li>CC </li></ul><ul><ul><li>OPQRST </li></ul></ul><ul><li>Distance and...
2° complaints / Sx <ul><li>Next ask about 2° Visual Symptoms and HA’s: </li></ul><ul><li>Ask RE: </li></ul><ul><ul><li>Dip...
2° Visual Symptoms <ul><li>Ask RE: Diplopia “Double Vision” </li></ul><ul><ul><li>If (+) ask Monocular vs Binocular </li><...
2° Visual Symptoms <ul><li>Ask RE: Photopsia “Flashes of lights” </li></ul><ul><ul><li>If (+) ask length of time the light...
2° Visual Symptoms <ul><li>Next ask about: “Headaches” </li></ul><ul><ul><li>If patient is positive for headaches then pro...
Headache Hx: <ul><li>1. Location: frontal, temporal, occipital, neck etc. </li></ul><ul><li>2. Family Hx of HA’s </li></ul...
Headache Hx: <ul><li>7. Character type: dull, sharp, burning etc. </li></ul><ul><li>8. Duration “how long to they last” </...
Character type :
Visual and Past Ocular Hx <ul><li>Ask about : Past Ocular Health </li></ul><ul><ul><li>The Last Eye Exam (LEE)  </li></ul>...
Visual and Past Ocular Hx <ul><li>Ask about : Past Ocular Health </li></ul><ul><ul><li>Contact Lens Hx </li></ul></ul><ul>...
What is a sequelae? <ul><li>By Defn: A sequela is any lesion or affection following or caused by an attack of disease </li...
What is a sequelae? <ul><li>Example: Patient reports being hit with a baseball and “breaking his cheek” years ago, he now ...
Patients Medical Hx <ul><li>Ask:  Last Medical Exam (LME __ yrs) </li></ul><ul><ul><li>If more than a few years (2-3) ask ...
Patients Medical Hx <ul><li>Ask about  the patient’s General Health: “Constitutional” System </li></ul><ul><ul><li>How the...
Patients Medical Hx <ul><li>Ask if  “Under care or Observation of a MD or clinic” </li></ul><ul><ul><li>NOTE: Care could b...
Patients Medical Hx <ul><li>If female ,  ask if pregnant or possibility ? – Teens to Fifty </li></ul><ul><li>Ask:  about a...
Two Most Important Questions in the PMHx <ul><li>1) Medications </li></ul><ul><li>Ask: “Are you taking any medication eith...
Two Most Important Questions in the PMHx <ul><li>1) Medications </li></ul><ul><li>IF yes then follow up with these : </li>...
Two Most Important Questions in the PMHx <ul><li>2) Allergies  </li></ul><ul><li>Next ask “Do you have any allergies to me...
Review of Systems (ROS) <ul><li>The eyes and associated symptoms rarely stand alone. </li></ul><ul><li>Most systems of the...
Review of Systems (ROS) <ul><li>E/M coding requirement </li></ul><ul><li>Must ask about 10 of the 14 for a comprehensive e...
Review of Systems (ROS) <ul><li>Must ask about three disorders/ diseases/symptoms in each system. </li></ul><ul><li>Can be...
Review of Systems (ROS) <ul><li>Follow the Review of Systems (ROS) choosing those body systems which impact the visual sys...
Review of Systems (ROS) <ul><li>Do not ask about the system in general terms, ask or give examples of disorders which you ...
Recording the ROS <ul><li>Record ALL positives and pertinent negatives. </li></ul><ul><li>Record as yes/no or (+) or (-). ...
Recording the ROS <ul><li>NOTE: If using (+) and (-) as yes and no, you must circle each.  </li></ul><ul><li>If not then +...
Family eye and Medical Hx:  FMHx <ul><li>Most often will be combined with patient’s own ROS: </li></ul><ul><li>Example: “I...
Family eye and Medical Hx:  FMHx <ul><li>Record as yes/no or (+) or (-). If positive for a family member then need a state...
Family eye and Medical Hx:  FMHx <ul><li>Example : (+) DM, mother, age 60, Tx “diet”, controlled </li></ul><ul><li>(+) HTN...
The ROS <ul><li>General Health  “Constitutional” : ask about fever, weight gain/loss, chronic fatigue </li></ul><ul><li>Ey...
The ROS <ul><li>Ears, nose, throat, and mouth : ask about sinus pain or problems, bleeding, hearing loss, sore throats or ...
The ROS <ul><li>Cardiovascular : Partly covered by blood pressure and cholesterol levels in PMHx but need also to ask abou...
The ROS <ul><li>Respiratory : ask about Hx of asthma, bronchitis (chronic cough), SOB, wheezing, chest pain. </li></ul><ul...
The ROS <ul><li>Genitourinary :  </li></ul><ul><ul><li>Females: are you pregnant or is there a possibility of pregnancy?  ...
Musculoskeletal <ul><li>Eye problems are very common in rheumatologic disorders. </li></ul><ul><ul><li>You can question fo...
Musculoskeletal <ul><li>If they answer NO to all three, it is not likely that any rheumatic disorder is present.  However,...
ROS <ul><li>Integumentary (skin and breast):  ask about skin conditions, i.e. rashes, moles, freckles, warts. </li></ul><u...
ROS <ul><li>Psychiatric : ask about depression, panic attacks, anxious tendencies, irregular sleep patterns. </li></ul><ul...
ROS <ul><li>Hematological/Lymphatic : ask about bruising, anemia (low blood iron), and problems with bleeding. Any swellin...
ROS <ul><li>In addition to the ROS ask about Cancers. </li></ul><ul><ul><li>NOTE: Cancer is NOT a system!   </li></ul></ul...
ROS <ul><li>NOTE : You must address 10 of the above 14 for a comprehensive exam.  You may ask more.  Some of the systems a...
ROS <ul><li>Example: Eye under POHx </li></ul><ul><li>General Health under PMHx, </li></ul><ul><li>Neurological under HAs ...
ROS <ul><li>Some systems need only be queried if the CC warrants. </li></ul><ul><ul><li>Example : Genitourinary. You will ...
ROS <ul><li>Keep in mind the history is never complete .  </li></ul><ul><li>You may have to return to the ROS in cases whe...
ROS <ul><li>Example : The finding of retinal hemorrhage would dictate review of the Hematological/Lymphatic system after i...
Social Hx : Vocational Requirements & Recreational Needs <ul><li>Ask vocation and be specific! </li></ul><ul><ul><ul><li>i...
Social Hx : Vocational Requirements & Recreational Needs <ul><li>Do they work on a computer (CRT), type of task and “Time ...
Social Hx : Vocational Requirements & Recreational Needs <ul><li>Ask if they have hobbies or other recreational activities...
Social Hx : Vocational Requirements & Recreational Needs <ul><li>Do they smoke or use tobacco? </li></ul><ul><ul><li>If ye...
Social Hx : Vocational Requirements & Recreational Needs <ul><li>Do they use recreational drugs? </li></ul><ul><li>Why? </...
Summary <ul><li>Before you leave the history we will review what we have recorded for the patient by saying: </li></ul><ul...
Summary <ul><li>2. Then review the signs and symptoms (Sx) of the CC and any positive (+) answers from the PMH, ROS or the...
Summary <ul><li>4. Then add: </li></ul><ul><li>“ Is there anything you would like to add that might have bearing on your e...
Summary <ul><li>With so many questions asked the patient may have forgotten to say something or you may have triggered som...
References <ul><li>Bickley, L  “Bates’s Guide to Physical Examination and History Taking” , 7 th  8th or 9th Ed. 1999, Lip...
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Lecture 3

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Lecture 3

  1. 1. V550 The History Questions Richard E. Meetz, OD, MS 2009
  2. 2. The Working Phase: <ul><li>Setting up the record </li></ul><ul><ul><li>Date and time </li></ul></ul><ul><ul><li>Demographics </li></ul></ul><ul><ul><li>Review patient’s intake form </li></ul></ul><ul><ul><li>Review patient’s previous exams </li></ul></ul>
  3. 3. Date and Time <ul><li>The full date must be on every record! </li></ul><ul><ul><li>Month / day / year </li></ul></ul><ul><ul><li>The month and day without the year </li></ul></ul><ul><ul><li>is a record lost to time; </li></ul></ul><ul><ul><li>just when did it happen? </li></ul></ul>
  4. 4. Date and Time <ul><li>Time should appear: </li></ul><ul><ul><li>Early in the examination (start) </li></ul></ul><ul><ul><li>With any application of pharmaceutical drops </li></ul></ul><ul><ul><li>With any test where time is a variable - Example pressures: IOPs, BPs, etc. </li></ul></ul><ul><ul><li>At the start of any treatment procedure </li></ul></ul>
  5. 5. Date and Time <ul><li>12 vs 24 hour clock? </li></ul><ul><ul><li>Not critical as long as reader can tell morning from afternoon. </li></ul></ul>
  6. 6. Demographics <ul><li>Name: Last Name, first name & middle initial </li></ul><ul><ul><li>Must be on every page of record! </li></ul></ul><ul><li>Age, Date of Birth (DOB) and Place of Birth </li></ul><ul><li>Sex, Marital status, Race or Ethnic group </li></ul><ul><li>Address and Telephone numbers </li></ul><ul><ul><li>both work & home, (cell?) </li></ul></ul><ul><li>SSN’s and Insurance Co. #’s </li></ul><ul><li>Vocation </li></ul>
  7. 7. What Questions to Ask? <ul><li>The series of questions and order will depend on the type of examination. </li></ul><ul><ul><li>Comprehensive vs problem orientated </li></ul></ul><ul><li>In this class and those in 2nd year, we will concentrate on the Comprehensive History. </li></ul>
  8. 8. What Questions to Ask? <ul><li>Always keep in mind that there is a reason for every question we will ask. </li></ul><ul><li>Know it! </li></ul><ul><li>Be able to explain it to the patient. </li></ul><ul><li>IN LAY terms </li></ul>
  9. 9. What Questions to Ask? <ul><li>The order needs to be logical! </li></ul><ul><ul><li>For both the clinician and the patient. </li></ul></ul><ul><ul><li>DO NOT JUMP AROUND! </li></ul></ul><ul><ul><ul><li>From one Sx to the next </li></ul></ul></ul><ul><ul><ul><li>From CC to Sx to POHx to PMHx to their ROS to the family’s medical Hx etc. </li></ul></ul></ul><ul><ul><li> </li></ul></ul><ul><ul><li>The question just asked needs to help the patient answer the next. </li></ul></ul>
  10. 10. The Reason for Seeking Care <ul><li>The Reason for Visit (RFV) </li></ul><ul><ul><li>Can be for a vision complain (CC) </li></ul></ul><ul><ul><ul><li>refractive </li></ul></ul></ul><ul><ul><ul><li>health </li></ul></ul></ul><ul><ul><li>Routine exam </li></ul></ul><ul><ul><ul><li>new patient </li></ul></ul></ul><ul><ul><ul><li>well checks (Ins, job req, application) </li></ul></ul></ul><ul><ul><li>Doctor recommended return </li></ul></ul><ul><ul><ul><li>One year glaucoma suspect, cataract check </li></ul></ul></ul>
  11. 11. The Reason for Seeking Care <ul><li>The Reason for Visit (RFV) </li></ul><ul><ul><li>“ The coverage of services rendered (payment of fees) is dependent on the purpose of the examination rather than the ultimate diagnosis of the patient’s condition” - CMS </li></ul></ul>
  12. 12. The Reason for Seeking Care <ul><li>The Reason for Visit (RFV) </li></ul><ul><ul><li>Chief complain (CC) </li></ul></ul><ul><ul><ul><li>“ Is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return or other factor that is the reason for the encounter, usually stated in the patient’s words”- CMS Manual </li></ul></ul></ul>
  13. 13. The Reason for Seeking Care <ul><li>The Reason for Visit (RFV) </li></ul><ul><ul><li>Routine exams that are not covered by CMS </li></ul></ul><ul><ul><ul><li>For the purpose of prescribing, fitting or changing eyeglasses, contact lenses </li></ul></ul></ul><ul><ul><ul><li>Examination performed without relationship (no CC) to treatment or diagnosis for a specific illness, symptom complaint or injury </li></ul></ul></ul><ul><ul><ul><li>Well checks for 3rd parties </li></ul></ul></ul><ul><ul><ul><ul><li>Insurance Co, job application </li></ul></ul></ul></ul>
  14. 14. The CMS <ul><li>The Centers for Medicare & Medicaid Services </li></ul><ul><ul><li>Federal agency responsible for management and oversight of both Medicare & Medicaid Services </li></ul></ul><ul><ul><li>Sets rules and regulations for fed reimbursable health care </li></ul></ul><ul><ul><ul><li>Evaluation and Management Service Codes “E/M” codes </li></ul></ul></ul><ul><ul><ul><li>Followed by most 3rd party payers </li></ul></ul></ul>
  15. 15. The Reason for Seeking Care <ul><li>Chief Complaint: CC </li></ul><ul><ul><li>Ask an open-ended question </li></ul></ul><ul><ul><li>Example: </li></ul></ul><ul><ul><ul><li>“ What is the reason for this visit” or </li></ul></ul></ul><ul><ul><ul><li>“ What problems/symptoms bring you to the office today?” </li></ul></ul></ul>
  16. 16. The Reason for Seeking Care <ul><li>Chief Complaint (cont’d) </li></ul><ul><ul><li>Record statement in the patient’s own words “in quotations”. </li></ul></ul><ul><ul><li>“ I have been having blurred vision when I’m driving my car” </li></ul></ul><ul><ul><ul><li>May shorten somewhat, but do not change meaning. </li></ul></ul></ul><ul><ul><ul><li>Telegraphing: “blurred vision when driving” </li></ul></ul></ul>
  17. 17. The Reason for Seeking Care <ul><li>History of present Illness: HPI </li></ul><ul><li>The goal of the HPI is to develop a Working Diagnosis of the patient’s problem (CC). </li></ul><ul><ul><li>The clinician must clearly understand the patients CC and symptoms(Sx) in order to solve them. </li></ul></ul><ul><ul><li>The HPI is a series of follow-up questions designed to help the historian </li></ul></ul>
  18. 18. History of Present Illness (HPI) <ul><li>Location </li></ul><ul><li>Quality </li></ul><ul><li>Severity </li></ul><ul><li>Duration </li></ul><ul><li>Timing </li></ul><ul><li>Context </li></ul><ul><li>Associated signs </li></ul><ul><li>Modifying factors </li></ul><ul><li>Symptoms </li></ul>For the HPI, questions are asked of the following 9 Sx characteristics:
  19. 19. History of Present Illness (HPI) <ul><li>NOTE : </li></ul><ul><li>You do not need to ask all 9 questions, only as many needed to understand the CC. </li></ul><ul><li>BUT you must address at least 4 of them AND RECORD THEM for the extended history of present illness requirement for a comprehensive exam (CMS). </li></ul>
  20. 20. Most Common History Pitfall: <ul><li>Not fully questioning the patient about the HPI. </li></ul><ul><ul><li>Reasons : </li></ul></ul><ul><ul><ul><li>Thinking you understand the patient </li></ul></ul></ul><ul><ul><ul><li>Rush to get into objective part of the examination </li></ul></ul></ul><ul><ul><ul><li>Patient is not a good historian </li></ul></ul></ul><ul><ul><ul><li>Patient in a rush to read the eye chart </li></ul></ul></ul>
  21. 21. Most Common History Pitfall: <ul><li>By not understanding the CC, you will spend too much time doing unnecessary testing or end up not solving the CC. </li></ul><ul><li>Fully understanding the CC is a MUST ! </li></ul>
  22. 22. 2nd Most Common History Pitfall: <ul><li>Not recording enough details of the HPI to support the level of care. </li></ul><ul><ul><li>For a comprehensive exam there must be 4 HPI following the CC </li></ul></ul><ul><ul><li>For a intermediate or problem focus (level 2) there needs to be 1-3 F/U questions of the HPI </li></ul></ul><ul><ul><li>Without documentation of the F/U questions exams are downgraded with less reimbursement </li></ul></ul>
  23. 23. Most Common Missed Question: <ul><li>Which eye or both? </li></ul>
  24. 24. Recording the CC & HPI <ul><li>Recorded in short words and phrases </li></ul><ul><ul><li>Example: After the CC, Patient says “The blurred vision has been happening for the last two months,I notice it late at night or when driving on the highway, and I can’t read the green signs until I get almost on top of them.” </li></ul></ul>
  25. 25. Recording the CC & HPI <ul><ul><li>You record : </li></ul></ul><ul><ul><li>CC: “blurred vision when driving”, late night or highway signs X 2 months </li></ul></ul>
  26. 26. Recording the CC & HPI <ul><ul><li>If patient’s RFV has no CC, then hold off recording ‘routine’ until end. </li></ul></ul><ul><ul><ul><li>May find problem later on in the exam. </li></ul></ul></ul><ul><ul><li>If not reported yet, ask next about distance and near vision with their Rx, if worn, before you are finished with the CC/HPI area. </li></ul></ul>
  27. 27. Hx mnemonics <ul><li>A mnemonic is a word or words that serve as a memory trigger for remembering steps or parts of </li></ul><ul><li>The are 3 that you will find useful for symptom analysis questions </li></ul><ul><ul><li>TADD </li></ul></ul><ul><ul><li>OPQRST </li></ul></ul><ul><ul><li>OLD CARTS </li></ul></ul>
  28. 28. TADD <ul><li>Used for F/U of all 2° Sx </li></ul><ul><ul><li>T ime of onset: 1 st date and time of day </li></ul></ul><ul><ul><li>A ssociation: aggravating factors or activity when noticed </li></ul></ul><ul><ul><li>D uration: how long it lasts/how often </li></ul></ul><ul><ul><li>D escription/severity </li></ul></ul><ul><li>These are the minimum # questions that must be asked of all positive symptoms from the patient. </li></ul>
  29. 29. Beyond TADD <ul><li>NOTE! </li></ul><ul><li>TADD is only the bare minimum f/u for any Sx. </li></ul><ul><li>You are not locked into TADD; you should expand your questioning when the symptoms warrant. </li></ul>
  30. 30. Beyond TADD <ul><li>OPQRST </li></ul><ul><li>Is a mnemonic for a better set of symptom analysis questions; </li></ul><ul><li>O= Onset </li></ul><ul><li>P= Provocative/Palliative </li></ul><ul><li>Q= Quality/Quantity </li></ul><ul><li>R= Region/Radiation </li></ul><ul><li>S= Severity/Scale </li></ul><ul><li>T= Timing ( frequency, duration) </li></ul>
  31. 31. OPQRST <ul><li>O= Onset </li></ul><ul><ul><li>Onset; when did it begin? </li></ul></ul><ul><ul><ul><li>Day, weeks, months ago? </li></ul></ul></ul><ul><ul><ul><li>Time of day, AM or PM? </li></ul></ul></ul><ul><li>P= provocative/palliative </li></ul><ul><ul><li>What causes the symptom? </li></ul></ul><ul><ul><li>What makes it better or worse? </li></ul></ul>
  32. 32. OPQRST <ul><li>P= </li></ul><ul><ul><li>Provocative= What makes it worse? </li></ul></ul><ul><ul><li>Palliative = What makes it better? </li></ul></ul><ul><li>Q= Quality /Quantity </li></ul><ul><ul><li>How does it feel, look, sound? </li></ul></ul><ul><ul><li>How bad is it now? Relative to previous times? </li></ul></ul><ul><ul><li>Can you keep up with your usual activities? </li></ul></ul>
  33. 33. OPQRST <ul><li>R= Region/Radiation </li></ul><ul><ul><li>Where does it occur? </li></ul></ul><ul><ul><li>Does it radiate? </li></ul></ul><ul><ul><li>Does it change? </li></ul></ul><ul><li>S= Severity/Scale </li></ul><ul><ul><li>How bad is it? </li></ul></ul><ul><ul><li>On a scale of 1-10 with 10 being the worst…. </li></ul></ul><ul><ul><ul><li>1 to 5 better! </li></ul></ul></ul>
  34. 34. OPQRST <ul><li>T= Timing </li></ul><ul><ul><li>Time of day, AM or PM? </li></ul></ul><ul><ul><li>Gradual or abrupt? </li></ul></ul><ul><ul><li>Frequency; How often? </li></ul></ul><ul><ul><ul><li>(Daily, weekly, monthly etc) </li></ul></ul></ul><ul><ul><li>Duration; How long? </li></ul></ul><ul><ul><ul><li>Constant or intermittent? </li></ul></ul></ul>
  35. 35. OLD CARTS <ul><li>Is a mnemonic similar to OPQRST; </li></ul><ul><li>O= Onset </li></ul><ul><li>L= Location </li></ul><ul><li>D= Duration </li></ul><ul><li>C= Character </li></ul><ul><li>A= Aggravating/alleviating Factors </li></ul><ul><li>R= Region/Radiation </li></ul><ul><li>T=Timing </li></ul><ul><li>S= Severity/Scale </li></ul>
  36. 36. Medical Charting <ul><li>Recording in the medical chart </li></ul><ul><li>In the busy medical office, there is a need for speed & to shorten record keeping. </li></ul><ul><li>Information, especially patient history and review of systems (ROS) are not and could not be recorded verbatim. </li></ul><ul><li>Health care providers use the technique of “Telegraphing” </li></ul>
  37. 37. Medical Charting <ul><li>Recording in the medical chart </li></ul><ul><li>“ Telegraphing” </li></ul><ul><ul><li>A technique of shortening chart entries by deleting all extraneous words. </li></ul></ul><ul><ul><ul><li>“ a, the, ands” etc. </li></ul></ul></ul><ul><ul><ul><li>But not so much that meaning is lost. </li></ul></ul></ul>
  38. 38. Medical Charting <ul><li>“ Telegraphing” </li></ul><ul><li>Example: full wording </li></ul><ul><li>The patient denies that he has had any drainage from his left eye. He also says that he has noticed no redness, has no tearing, has experienced no photophobia nor does he have any pain in that eye. </li></ul><ul><li>5 lines, 38 words </li></ul>
  39. 39. Medical Charting <ul><li>“ Telegraphing” </li></ul><ul><li>Example: telegraphed </li></ul><ul><li>Patient denies any drainage, redness, tearing, photophobia or pain in left eye. </li></ul><ul><li>2 lines, 12 words </li></ul>
  40. 40. Medical Charting <ul><li>Recording the Chief Complaint </li></ul><ul><li>The CC must be in the patients own words! </li></ul><ul><li>Placed in “Quotes” </li></ul><ul><ul><li>In the CC no words are changed! </li></ul></ul><ul><ul><li>But may be telegraphed </li></ul></ul>
  41. 41. Medical Charting <ul><li>Recording the Chief Complaint </li></ul><ul><li>Example: full wording </li></ul><ul><ul><li>Patient reports “when I’m driving those green highway signs are hard to read at night” </li></ul></ul><ul><ul><li>You record CC: “green highway signs hard to read at night” </li></ul></ul><ul><ul><li>Do not record: </li></ul></ul><ul><ul><ul><li>CC: “signs hard to read” or </li></ul></ul></ul><ul><ul><ul><li>CC: “Patient reports blur at night” </li></ul></ul></ul>
  42. 42. Medical Charting <ul><li>Recording the Chief Complaint </li></ul><ul><li>Bad Examples: </li></ul><ul><ul><ul><ul><li>( from the Jo of Court Reporting) </li></ul></ul></ul></ul><ul><ul><li>Patient has chest pain if she lies on her left side for over a year. </li></ul></ul><ul><ul><li>The patient is tearful and crying constantly. She also appears to be depressed. </li></ul></ul><ul><ul><li>When she fainted her eyes rolled around the room. </li></ul></ul><ul><ul><li>She has had no rigors or shaking chills, but her husband states she was very hot in bed last night. </li></ul></ul>
  43. 43. Medical Charting <ul><li>Recording the Chief Complaint </li></ul><ul><li>Bad Examples:Missing words? </li></ul><ul><ul><ul><ul><ul><li>( from the Jo of Court Reporting) </li></ul></ul></ul></ul></ul><ul><ul><li>Bleeding started in the rectal area and continued all the way to LA. </li></ul></ul><ul><ul><li>She stated that she had been constipated for most of her life until 1989 when she got a divorce. </li></ul></ul><ul><ul><li>The patient states there is a burning pain in his penis, which goes to the floor. </li></ul></ul><ul><ul><li>The patient has no past history of suicides. </li></ul></ul>
  44. 44. Medical Charting <ul><li>Recording the Chief Complaint </li></ul><ul><li>Bad Examples:Conflicts! </li></ul><ul><ul><ul><ul><li>(from the Jo of Court Reporting) </li></ul></ul></ul></ul><ul><ul><li>Occasional, constant, infrequent headaches. </li></ul></ul><ul><ul><li>Patient was alert and unresponsive. </li></ul></ul><ul><ul><li>The skin was moist and dry. </li></ul></ul><ul><ul><li>Healthy appearing decrepit 69 year-old male, mentally alert but forgetful. </li></ul></ul>
  45. 45. Symptomatology <ul><li>Is the art of recognizing the classical symptoms of diseases and disorders and how patients typically describe them </li></ul>
  46. 46. Common Refractive Sx <ul><li>1. Hyperopia – “Far sighted” – not enough power or eye is too short. Patient can accommodate to clear the distance, but then has to focus more to see near. </li></ul><ul><li>CC: No distance or near blur but will complain of: “eye strain” </li></ul><ul><ul><ul><li>School age to 50’s </li></ul></ul></ul><ul><ul><ul><li>Late in day or after near tasks </li></ul></ul></ul>
  47. 47. Common Refractive Sx <ul><li>2.Myopia – “Near sighted” – Too much power or eye is too long. Eyes are focus for near. </li></ul><ul><li>CC is </li></ul><ul><ul><li>“ Distance blur and clear up close” </li></ul></ul><ul><ul><ul><li>School age to 20’s </li></ul></ul></ul><ul><ul><ul><li>Constant, worse at night, squinting helps </li></ul></ul></ul>
  48. 48. Common Refractive Sx <ul><li>3. Astigmate – Warpage of cornea causing a slight blur or “double” image at all distances. </li></ul><ul><li>CC: “ Blur or shadow around letters” or “ghost images” and even monocular double vision </li></ul><ul><ul><ul><li>School age to 40’s </li></ul></ul></ul><ul><ul><ul><li>All distances but most noticeable at near or on video screens </li></ul></ul></ul>
  49. 49. Common Refractive Sx <ul><li>4. Presbyopia – Loss of near focus as part of normal aging. Can occur with any of the above refractive errors. </li></ul><ul><li>CC: Complains of eye strain, loss of close reading, difficulty in dim light and/or “arms are too short” </li></ul><ul><ul><ul><li>Adult age 39 and up </li></ul></ul></ul><ul><ul><ul><li>Stable after age 54 and up </li></ul></ul></ul>
  50. 50. Common Binocular Sx <ul><li>5. Accommodative Dysfunction – inability to hold clear near vision or a spasm of near focus in under 35 yo. </li></ul><ul><li>CC: “Words blur after 10 to 20 min of near work with HAs & distance blur after reading.” </li></ul>
  51. 51. Common Binocular Sx <ul><li>Accommodative Dysfunction </li></ul><ul><ul><ul><li>Typically school age to mid 20’s </li></ul></ul></ul><ul><ul><ul><li>Most notable at near or on video screens, but may see distance blur after reading </li></ul></ul></ul><ul><ul><ul><ul><li>Either will have to hold closer to read or </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Accommodative spasm </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Will have to push away </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Accommodative insufficiency </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Watch for side effects of medication </li></ul></ul></ul><ul><ul><ul><ul><li>Many cause accommodation problems </li></ul></ul></ul></ul>
  52. 52. Common Binocular Sx <ul><li>6. Binocular Dysfunction/Vergence Dysfunction – Extra ocular muscle’s inability to hold single clear vision. </li></ul><ul><li>CC: “Double vision at night”, </li></ul><ul><li>“ Double vision when reading” </li></ul><ul><li>“ Discomfort around eyes”, </li></ul><ul><li>“ Words run together or move during reading”, </li></ul><ul><li>“ Skipping lines when reading or loss of place” </li></ul>
  53. 53. Common Binocular Sx <ul><li>Binocular Dysfunction/Vergence Dysfunction (cont’d ) </li></ul><ul><ul><ul><li>School age to 40’s </li></ul></ul></ul><ul><ul><ul><li>Most notable at near or video screens, but may see distance complaints at night, intermittent </li></ul></ul></ul><ul><ul><ul><li>Adjusted postures common </li></ul></ul></ul><ul><ul><ul><ul><li>headtilt </li></ul></ul></ul></ul>
  54. 54. Common Ocular Sx <ul><li>7. Optical Quality/ Optical Distortion </li></ul><ul><ul><li>Loss of sharp optic transmission due to degrading of tears, cornea or lens. </li></ul></ul><ul><li>CC: </li></ul><ul><ul><li>“ Difficulty with glaring lights” or </li></ul></ul><ul><ul><li>“ Constant or occasional distance blur” </li></ul></ul><ul><ul><li>“ decrease in night vision” </li></ul></ul><ul><ul><li>“ Halos or rings around lights” </li></ul></ul>
  55. 55. Common Ocular Sx <ul><li>Optical Quality/Distortion (cont’d) </li></ul><ul><ul><ul><li>40 y.o. and up </li></ul></ul></ul><ul><ul><ul><li>CL wearers </li></ul></ul></ul><ul><ul><ul><li>Often with Sx of burning or dry eyes </li></ul></ul></ul><ul><ul><ul><ul><li>With allergy Sx </li></ul></ul></ul></ul><ul><ul><ul><li>Often at distance after video screen task or driving </li></ul></ul></ul><ul><ul><ul><li>If fluctuation in vision think tears (Sx over a few min)or Diabetes(fluctuation day to day) </li></ul></ul></ul><ul><ul><ul><li>If constant think cornea or lens (cataract) </li></ul></ul></ul>
  56. 56. Common Ocular Sx <ul><li>8. Diplopia – Symptoms of double vision, can be binocular (vergence or neurologic) or monocular (optical or retinal) </li></ul><ul><li>CC: “ghost images” or </li></ul><ul><ul><li>“ lights double at night” </li></ul></ul>
  57. 57. Common Ocular Sx <ul><li>Diplopia (cont’d) </li></ul><ul><ul><ul><li>Any age, Sx clear-cut or vague </li></ul></ul></ul><ul><ul><ul><li>Sx may be persistent or intermittent </li></ul></ul></ul><ul><ul><ul><li>Older pts CC of monocular diplopia: 2° to cataracts </li></ul></ul></ul><ul><ul><ul><li>Older pts CC binocular diplopia: decompensating vertical phoria </li></ul></ul></ul><ul><ul><ul><li>Sudden onset on any incomitant binocular Sx: neurologic </li></ul></ul></ul>
  58. 58. Common Ocular Sx <ul><li>9. Photopsia – Spontaneous flash or spark of light or slow flicking streaks or spectrums. </li></ul><ul><li>CC: </li></ul><ul><ul><li>“ saw a light bulb flash” or </li></ul></ul><ul><ul><li>“ zig-zag lines” </li></ul></ul><ul><ul><li>“ Blue streaks at night” </li></ul></ul><ul><ul><li>“ stars or sparkles” </li></ul></ul>
  59. 59. Common Ocular Sx <ul><li>Photopsia (cont’d) </li></ul><ul><ul><ul><li>Any age (teens and up) </li></ul></ul></ul><ul><ul><ul><li>Assoc. S&S of HTN, HA, trauma, retinal detachment, stroke, vertigo </li></ul></ul></ul><ul><ul><ul><li>Can be short (Vitroretinal) or long (20 min. Vascular) </li></ul></ul></ul><ul><ul><ul><li>Most common Vitroretinal cause is floaters </li></ul></ul></ul><ul><ul><ul><li>Most common Vascular cause is Migraine </li></ul></ul></ul>
  60. 60. Common Ocular Sx <ul><li>10. Ocular Discomfort – Sx vary from asthenopia to compelling pain arising or localizing in the eye or peri-ocular tissues. </li></ul><ul><li>CC: “ache around my eye” or </li></ul><ul><ul><li>“ irritation or burning” </li></ul></ul><ul><ul><li>“ pain when I blink” </li></ul></ul><ul><ul><li>“ lights hurt my eyes” </li></ul></ul>
  61. 61. Common Ocular Sx <ul><li>Ocular Discomfort (cont’d) </li></ul><ul><ul><li>Often with other S&S of redness, tearing, HAs, FBs </li></ul></ul><ul><ul><li>Often assoc. with refractive errors, vergences, lighting, time at near tasks, stress, allergies </li></ul></ul><ul><ul><li>Most common ache around eyes: sinus or teeth </li></ul></ul><ul><ul><li>Most common irritation or burning: dry eyes </li></ul></ul>
  62. 62. Common Ocular Sx <ul><li>11. Red eyes – Increased visibility of conjunctival vessels. Sx range from a mild sting or irritation to compelling pain and nausea. </li></ul><ul><li>CC: “Eye turned blood red” or </li></ul><ul><ul><li>“ road map eyes” </li></ul></ul><ul><ul><li>“ lids stuck together” </li></ul></ul><ul><ul><li>“ dry and burning eyes” </li></ul></ul>
  63. 63. Common Ocular Sx <ul><li>Red eyes (cont’d) </li></ul><ul><ul><ul><li>Any age </li></ul></ul></ul><ul><ul><ul><li>Often with allergies, CL, exposure, infections, medications, pollutants, trauma, uveitis </li></ul></ul></ul><ul><ul><ul><li>Most common in young: conjunctivitis “pink eye” </li></ul></ul></ul><ul><ul><ul><li>Most common in adults: dry eyes/poor tears </li></ul></ul></ul>
  64. 64. Common Ocular Sx <ul><li>12. Halos or rays – Reports of rings around light or streaks shooting out of lights at night. Due to edema or H 2 O in the cornea or lens. </li></ul><ul><li>(See also “Optical Quality/Distortion”) </li></ul><ul><li>CC: “Halos or rings around lights”, “Difficulty with glaring lights” or “Lights look like shooting stars” </li></ul>
  65. 65. Common Ocular Sx <ul><li>Halos or rays (cont’d) </li></ul><ul><ul><ul><li>Contact lens wearers and </li></ul></ul></ul><ul><ul><ul><li>Older persons </li></ul></ul></ul><ul><ul><ul><li>Assoc. with glaucoma, corneal degeneration, cataracts, DM </li></ul></ul></ul><ul><ul><ul><li>If younger, think corneal/tears </li></ul></ul></ul><ul><ul><ul><li>If older, think lens (cataract) </li></ul></ul></ul>
  66. 66. Common Ocular Sx <ul><li>13. Photophobia – Abnormal sensitivity to light. </li></ul><ul><li>* Ocular pain with light. </li></ul><ul><li>CC: </li></ul><ul><ul><li>“ Have to wear sunglasses when I go out in daylight” </li></ul></ul><ul><ul><li>“ I can’t open my eyes up in the light” </li></ul></ul><ul><ul><li>“ lights make my eyes water” </li></ul></ul><ul><ul><li>“ on coming car lights are painful” </li></ul></ul>
  67. 67. Common Ocular Sx <ul><li>Photophobia (cont’d) </li></ul><ul><ul><ul><li>Any age, most often young, blue eyes (idiopathic) </li></ul></ul></ul><ul><ul><ul><li>Often with infections, medications, trauma, uveitis </li></ul></ul></ul>
  68. 68. Common Ocular Sx <ul><li>Photophobia (cont’d) </li></ul><ul><ul><li>Important F/U question for a Photophobia patient </li></ul></ul><ul><ul><li>“ Does the eye hurt when it is covered and a light is shown into the other eye?” </li></ul></ul><ul><ul><li>If “yes” think uveitis </li></ul></ul>
  69. 69. Common Ocular Sx <ul><li>14. Vision Loss – Diminution of vision in part or all of the visual field in one or both eyes. Constant or episodic visual disturbances. </li></ul><ul><li>Gradual or sudden. </li></ul><ul><li>CC: “Can’t see out of one eye”, “having vision spells”, “can’t see to one side”, “hole in the center of my vision” </li></ul>
  70. 70. Common Ocular Sx <ul><li>Vision Loss (cont’d) </li></ul><ul><ul><ul><li>Older patients but can be teens and up </li></ul></ul></ul><ul><ul><ul><li>Often with other S&S of cataracts, CHD/CVD, HTN, HA, migraine, trauma, TIA, stroke, smoking, vertigo, etc. </li></ul></ul></ul><ul><ul><ul><li>Episodic may last minutes to hours, think vascular </li></ul></ul></ul><ul><ul><ul><li>Gradual constant loss most often retinal or optical </li></ul></ul></ul>
  71. 71. Common Ocular Sx <ul><li>15. Headache – Reports of pain discomfort around, top of, through, under the head. See also above symptoms. </li></ul><ul><li>CC: “Headache” </li></ul><ul><ul><ul><li>Children and up </li></ul></ul></ul>
  72. 72. <ul><li>Headache (cont’d) </li></ul><ul><ul><li>Assoc. with many symptoms and etiologies </li></ul></ul><ul><ul><li>Symptoms Type </li></ul></ul><ul><ul><li>Pain Sinus </li></ul></ul><ul><ul><li>Nausea Migraine </li></ul></ul><ul><ul><li>Photophobia Cluster </li></ul></ul><ul><ul><li>HTN CNS Bleeds (Strokes) </li></ul></ul><ul><ul><li>Visual Loss HTN </li></ul></ul><ul><ul><li>Congestion Asthenopia </li></ul></ul><ul><ul><li>Fatigue Tension (muscle) </li></ul></ul><ul><ul><li>Hemiparesis Hypoglycemic </li></ul></ul><ul><ul><li>Vertigo Giant Cell arteritis </li></ul></ul><ul><ul><li>Fever TMJ </li></ul></ul><ul><ul><li>Depression Tumor </li></ul></ul><ul><ul><li>Photopsia Cranial Bleeds </li></ul></ul><ul><ul><li>Scalp tenderness Concussion </li></ul></ul><ul><ul><li>Tearing Toxic (drug) </li></ul></ul><ul><ul><li>Vomiting Glaucoma </li></ul></ul><ul><ul><li>Neck Stiffness Meningitis </li></ul></ul>
  73. 73. Back to the Hx: <ul><li>Demographics </li></ul><ul><li>CC </li></ul><ul><ul><li>OPQRST </li></ul></ul><ul><li>Distance and near blur </li></ul><ul><li>2° Visual Symptoms and HA </li></ul><ul><li>POHx </li></ul><ul><li>PMHx </li></ul><ul><li>ROS and family MHx </li></ul><ul><li>SHx </li></ul>
  74. 74. 2° complaints / Sx <ul><li>Next ask about 2° Visual Symptoms and HA’s: </li></ul><ul><li>Ask RE: </li></ul><ul><ul><li>Diplopia </li></ul></ul><ul><ul><li>Halos </li></ul></ul><ul><ul><li>Flashes of lights </li></ul></ul><ul><ul><li>Floaters </li></ul></ul><ul><ul><li>Seizures </li></ul></ul><ul><ul><li>Headaches </li></ul></ul>
  75. 75. 2° Visual Symptoms <ul><li>Ask RE: Diplopia “Double Vision” </li></ul><ul><ul><li>If (+) ask Monocular vs Binocular </li></ul></ul><ul><ul><li>“ Shadows or true double vision?” </li></ul></ul><ul><li>Ask RE: Halos “Rings around lights” </li></ul><ul><ul><li>With or with out Rx? </li></ul></ul><ul><ul><li>R/O Glaucoma vs Corneal Degeneration, Cataracts or Edema </li></ul></ul>
  76. 76. 2° Visual Symptoms <ul><li>Ask RE: Photopsia “Flashes of lights” </li></ul><ul><ul><li>If (+) ask length of time the lights appear; </li></ul></ul><ul><ul><li>short flash (1 to 3 seconds) = Retinal vs </li></ul></ul><ul><ul><li>Longer flash (1/2 min to 30 min) = vascular) </li></ul></ul><ul><li>Ask RE: “Floaters” New or changes </li></ul><ul><li>Ask RE: “Seizures” Hx or under care </li></ul><ul><li>“ TADD” for each positive Sx. </li></ul>
  77. 77. 2° Visual Symptoms <ul><li>Next ask about: “Headaches” </li></ul><ul><ul><li>If patient is positive for headaches then proceed to the HA line of questions. </li></ul></ul>
  78. 78. Headache Hx: <ul><li>1. Location: frontal, temporal, occipital, neck etc. </li></ul><ul><li>2. Family Hx of HA’s </li></ul><ul><li>3. 1 st started having HA’s: ‘age’ </li></ul><ul><li>4. Time of onset; am vs pm </li></ul><ul><li>5. Frequency “How often” “Change in freq” </li></ul><ul><li>6. Intensity or pain level; scale(??) </li></ul><ul><ul><li>Better ask “Can you still work?” </li></ul></ul>
  79. 79. Headache Hx: <ul><li>7. Character type: dull, sharp, burning etc. </li></ul><ul><li>8. Duration “how long to they last” </li></ul><ul><li>9. Cause or Assoc: i.e. eating, reading, work, stress, CRT’s </li></ul><ul><li>10. Description </li></ul><ul><li>11. Treatments and do the Txs work? </li></ul>
  80. 80. Character type :
  81. 81. Visual and Past Ocular Hx <ul><li>Ask about : Past Ocular Health </li></ul><ul><ul><li>The Last Eye Exam (LEE) </li></ul></ul><ul><ul><ul><li>How many years? </li></ul></ul></ul><ul><ul><li>The Dr.’s name and location </li></ul></ul><ul><ul><li>The last time their eyes were dilated (DFE) </li></ul></ul><ul><ul><ul><li>Last DFE _#_ years </li></ul></ul></ul><ul><ul><li>Age of present Rx and </li></ul></ul><ul><ul><ul><li>age 1 st Rx worn </li></ul></ul></ul>
  82. 82. Visual and Past Ocular Hx <ul><li>Ask about : Past Ocular Health </li></ul><ul><ul><li>Contact Lens Hx </li></ul></ul><ul><ul><ul><li>usage, type, CL wearing time and care </li></ul></ul></ul><ul><ul><li>Hx of trauma or infection, </li></ul></ul><ul><ul><ul><li>any treatments and any sequelae </li></ul></ul></ul><ul><ul><li>Visual Training (VT) or patching </li></ul></ul>
  83. 83. What is a sequelae? <ul><li>By Defn: A sequela is any lesion or affection following or caused by an attack of disease </li></ul><ul><li>OUR use : Any residual signs or symptoms of a past disease, surgery, treatment or trauma. </li></ul>
  84. 84. What is a sequelae? <ul><li>Example: Patient reports being hit with a baseball and “breaking his cheek” years ago, he now reports an increase in sinus headaches (HA) on that side. </li></ul><ul><ul><li>sinus HAs are now a sequelae </li></ul></ul><ul><li>Example: Patient reports seeing double when he looks up and to the right ever sense he fell out of a tree as a child. </li></ul><ul><ul><li>Diplopia is his sequelae </li></ul></ul>
  85. 85. Patients Medical Hx <ul><li>Ask: Last Medical Exam (LME __ yrs) </li></ul><ul><ul><li>If more than a few years (2-3) ask further questions esp. females </li></ul></ul><ul><ul><ul><li>Females usually yearly </li></ul></ul></ul><ul><ul><ul><li>Males last visit 10+ years common. </li></ul></ul></ul><ul><ul><ul><li>NOTE: If on a Rx medication the LME must be within 1 year! </li></ul></ul></ul><ul><li>MD’s name and location </li></ul>
  86. 86. Patients Medical Hx <ul><li>Ask about the patient’s General Health: “Constitutional” System </li></ul><ul><ul><li>How they feel? </li></ul></ul><ul><ul><li>Fever? </li></ul></ul><ul><ul><li>Fatigue? </li></ul></ul><ul><ul><li>Recent weight loss? </li></ul></ul><ul><li>Last ‘Blood Pressure’ and date, Cholesterol level if known? </li></ul>
  87. 87. Patients Medical Hx <ul><li>Ask if “Under care or Observation of a MD or clinic” </li></ul><ul><ul><li>NOTE: Care could be as simple as BP checks every 6 mos. Checking a skin freckle once yearly. </li></ul></ul><ul><ul><li>IF USING Rx Medications they MUST BE SEEN YEARLY! </li></ul></ul><ul><ul><li>That would be UNDER CARE. </li></ul></ul>
  88. 88. Patients Medical Hx <ul><li>If female , ask if pregnant or possibility ? – Teens to Fifty </li></ul><ul><li>Ask: about any traumas or surgery? </li></ul><ul><ul><li>Any sequelae? </li></ul></ul><ul><ul><ul><li>Especially Head Traumas </li></ul></ul></ul><ul><li>Note: DO NOT ask about “Traumas” </li></ul><ul><li>Ask about; “being hit in the head or eye” </li></ul>
  89. 89. Two Most Important Questions in the PMHx <ul><li>1) Medications </li></ul><ul><li>Ask: “Are you taking any medication either prescription or non-prescription “Over the Counter” (OTC) ?” </li></ul><ul><li>Ask: “Are you using any drops?” </li></ul><ul><ul><ul><li>Patients often do not think of drops as medications </li></ul></ul></ul>
  90. 90. Two Most Important Questions in the PMHx <ul><li>1) Medications </li></ul><ul><li>IF yes then follow up with these : </li></ul><ul><li>1. Ask what medication, dose, reason, length of time. </li></ul><ul><li>2. Then ask about compliance: “Are you good about taking it as you have been instructed?” </li></ul>
  91. 91. Two Most Important Questions in the PMHx <ul><li>2) Allergies </li></ul><ul><li>Next ask “Do you have any allergies to medications?” (KMA) and </li></ul><ul><li>“ Do you have any other allergies: dust, pollen, food, bees, etc.” (KEA) </li></ul><ul><li>If YES list: What to, when, the type of reaction (Rxn) and treatment (Tx) if needed. </li></ul>
  92. 92. Review of Systems (ROS) <ul><li>The eyes and associated symptoms rarely stand alone. </li></ul><ul><li>Most systems of the body can be influenced by disorders of the eyes and the eyes by disorders of rest of the body. </li></ul><ul><li>Any drug taken for any reason will have an effect on the eyes and vision. Some noticeable, some not. </li></ul>
  93. 93. Review of Systems (ROS) <ul><li>E/M coding requirement </li></ul><ul><li>Must ask about 10 of the 14 for a comprehensive examination. </li></ul><ul><ul><li>One will be the organ of the CC. </li></ul></ul><ul><ul><ul><li>For us ‘the eye and vision’ </li></ul></ul></ul><ul><ul><li>One will be General Health or the ‘constitutional’ system </li></ul></ul>
  94. 94. Review of Systems (ROS) <ul><li>Must ask about three disorders/ diseases/symptoms in each system. </li></ul><ul><li>Can be asked as a list but need to stop after each to let patient respond. </li></ul>
  95. 95. Review of Systems (ROS) <ul><li>Follow the Review of Systems (ROS) choosing those body systems which impact the visual system or the patient’s CC. </li></ul><ul><li>Example: </li></ul><ul><li>If about to prescribe an oral medications ask </li></ul><ul><li>RE: GI symptoms and past disorders </li></ul>
  96. 96. Review of Systems (ROS) <ul><li>Do not ask about the system in general terms, ask or give examples of disorders which you are looking for: </li></ul><ul><li>DON’T : “Do you have any hematological problems?” </li></ul><ul><li>DO : “Do you have any problems with bleeding, bruises, anemia or low iron?” </li></ul>
  97. 97. Recording the ROS <ul><li>Record ALL positives and pertinent negatives. </li></ul><ul><li>Record as yes/no or (+) or (-). If positive then need a statement for each disorder along with age of onset and Tx. Record under “Personal or Patient’s Medical History (PMHx)”. </li></ul>
  98. 98. Recording the ROS <ul><li>NOTE: If using (+) and (-) as yes and no, you must circle each. </li></ul><ul><li>If not then + means “ and ” or “ add ”, and – means “ minus power ” or just a “ dash ”. </li></ul>
  99. 99. Family eye and Medical Hx: FMHx <ul><li>Most often will be combined with patient’s own ROS: </li></ul><ul><li>Example: “I’m going to ask you about several diseases and disorders, and if you or anyone in your family has any history of them, please tell me.” </li></ul>
  100. 100. Family eye and Medical Hx: FMHx <ul><li>Record as yes/no or (+) or (-). If positive for a family member then need a statement for each family member along with age of onset and Tx under the FMHx. If positive for self then record under the PMHx. </li></ul><ul><li>Record: (+) Dz, who, age, Tx, status </li></ul>
  101. 101. Family eye and Medical Hx: FMHx <ul><li>Example : (+) DM, mother, age 60, Tx “diet”, controlled </li></ul><ul><li>(+) HTN, father, age 40, Tx “diet and pills”, controlled </li></ul><ul><li>(+) CA, PG mother, age 70, Tx surgery, deceased </li></ul>
  102. 102. The ROS <ul><li>General Health “Constitutional” : ask about fever, weight gain/loss, chronic fatigue </li></ul><ul><li>Eyes : In addition to POHx ask about family ocular history (FOHx) of glaucoma, retinal detachment, macular degeneration, crossed eyes, blindness, early onset cataracts. </li></ul>
  103. 103. The ROS <ul><li>Ears, nose, throat, and mouth : ask about sinus pain or problems, bleeding, hearing loss, sore throats or hoarseness, difficulty swallowing, neck swelling. </li></ul>
  104. 104. The ROS <ul><li>Cardiovascular : Partly covered by blood pressure and cholesterol levels in PMHx but need also to ask about heart problems, shortness of breath (SOB), swelling of the extremities (ankles), chest pain , Hx of murmurs or irregular beats. Strokes ? </li></ul>
  105. 105. The ROS <ul><li>Respiratory : ask about Hx of asthma, bronchitis (chronic cough), SOB, wheezing, chest pain. </li></ul><ul><li>Gastrointestinal : the big one is: do you have ulcers ? Others: abdominal pain, nausea, vomiting, food intolerance. </li></ul>
  106. 106. The ROS <ul><li>Genitourinary : </li></ul><ul><ul><li>Females: are you pregnant or is there a possibility of pregnancy? </li></ul></ul><ul><ul><li>Both: do you experience pain or burning on urination, blood, discharge? </li></ul></ul><ul><li>Musculoskeletal : Arthritis, joint pain swelling, muscle weakness, scoliosis, back pain(esp in AM>1hr), gout, hand pains or temperature intolerance. </li></ul>
  107. 107. Musculoskeletal <ul><li>Eye problems are very common in rheumatologic disorders. </li></ul><ul><ul><li>You can question for rheumatic disorders easily by asking 3 specific questions: </li></ul></ul><ul><ul><li>Do you experience pain or stiffness in your neck, back, muscles or joints? </li></ul></ul><ul><ul><li>Do you have difficulty dressing yourself completely? </li></ul></ul><ul><ul><li>Do you have difficulty walking up and down stairs? </li></ul></ul>
  108. 108. Musculoskeletal <ul><li>If they answer NO to all three, it is not likely that any rheumatic disorder is present. However, some rarer rheumatic disorders still would not be covered by this but most would. </li></ul><ul><li>If using a computer >2 hrs, ask re: Carpel Tunnel Sx? </li></ul>
  109. 109. ROS <ul><li>Integumentary (skin and breast): ask about skin conditions, i.e. rashes, moles, freckles, warts. </li></ul><ul><ul><li>If any reported ask about “Changes” </li></ul></ul><ul><li>Neurological : Partially covered in 2° Visual Sx (double vision and HAs) but also ask about tumors, seizures , dizziness , weakness and fainting. </li></ul>
  110. 110. ROS <ul><li>Psychiatric : ask about depression, panic attacks, anxious tendencies, irregular sleep patterns. </li></ul><ul><li>Endocrine : ask about diabetes, thyroid, intolerance to temperature, growth, sudden or recent weight loss or gain. </li></ul>
  111. 111. ROS <ul><li>Hematological/Lymphatic : ask about bruising, anemia (low blood iron), and problems with bleeding. Any swelling of glands? Ask blood type. </li></ul><ul><li>Allergic/Immunologic : partly covered under KMA/KEA and sinuses but also, Immunizations? </li></ul>
  112. 112. ROS <ul><li>In addition to the ROS ask about Cancers. </li></ul><ul><ul><li>NOTE: Cancer is NOT a system! </li></ul></ul><ul><ul><li>It can occur in any system. </li></ul></ul><ul><ul><li>Most important to eye are: Skin (melanoma) Lung and breast </li></ul></ul>
  113. 113. ROS <ul><li>NOTE : You must address 10 of the above 14 for a comprehensive exam. You may ask more. Some of the systems are partly addressed elsewhere in the history so they do not need to be repeated for the personal ROS Hx. </li></ul>
  114. 114. ROS <ul><li>Example: Eye under POHx </li></ul><ul><li>General Health under PMHx, </li></ul><ul><li>Neurological under HAs and 2° CC. </li></ul><ul><li>Note the 10 systems requirement only applies to the patient’s health Hx. It does not apply to the family Medical Hx . </li></ul>
  115. 115. ROS <ul><li>Some systems need only be queried if the CC warrants. </li></ul><ul><ul><li>Example : Genitourinary. You will ask every time of all females of child bearing age about the possibility of pregnancy. </li></ul></ul><ul><ul><li>But other questions: “do you experience pain or burning on urination, blood, discharge” would only be asked if needed. </li></ul></ul><ul><ul><ul><li>Ex: the patient presented with a red eye of 4+ week duration or if antibiotic Tx has failed. </li></ul></ul></ul>
  116. 116. ROS <ul><li>Keep in mind the history is never complete . </li></ul><ul><li>You may have to return to the ROS in cases where your exam findings indicate the need for further information of less commonly asked systems. </li></ul>
  117. 117. ROS <ul><li>Example : The finding of retinal hemorrhage would dictate review of the Hematological/Lymphatic system after its detection. </li></ul><ul><li>A finding of a subconjunctival hemorrhage or if about to give an oral medication; Gastrointestinal would need to be reviewed. </li></ul>
  118. 118. Social Hx : Vocational Requirements & Recreational Needs <ul><li>Ask vocation and be specific! </li></ul><ul><ul><ul><li>i.e. if student, what type? Grade? Grad? Area? Needs are different. </li></ul></ul></ul><ul><ul><ul><li>If teacher, what level? Kg? HS? </li></ul></ul></ul><ul><li>Ask what is their vision task? TAT? Lighting </li></ul><ul><li>Ask if in OSHA area (When appropriate!) </li></ul><ul><ul><ul><li>Ex: Don’t ask a 70 yo secretary. </li></ul></ul></ul><ul><ul><ul><li>But do ask a collage Chem student! </li></ul></ul></ul>
  119. 119. Social Hx : Vocational Requirements & Recreational Needs <ul><li>Do they work on a computer (CRT), type of task and “Time at Task” (TAT)? </li></ul><ul><ul><li>NOTE : at 2+hr “time at task” patient’s ocular Sx jump in frequency X2. </li></ul></ul><ul><li>Do they read and amt of time? </li></ul>
  120. 120. Social Hx : Vocational Requirements & Recreational Needs <ul><li>Ask if they have hobbies or other recreational activities. </li></ul><ul><ul><li>Looking for risks and special Rx needs </li></ul></ul><ul><ul><li>High adds, polycarb lenses, etc. </li></ul></ul>
  121. 121. Social Hx : Vocational Requirements & Recreational Needs <ul><li>Do they smoke or use tobacco? </li></ul><ul><ul><li>If yes, ask amount: pack per day for __ yrs. </li></ul></ul><ul><ul><li>Important in ARMD </li></ul></ul><ul><li>Do they use alcohol? Estimate amount. </li></ul><ul><ul><li>Especially important in trauma cases. </li></ul></ul>
  122. 122. Social Hx : Vocational Requirements & Recreational Needs <ul><li>Do they use recreational drugs? </li></ul><ul><li>Why? </li></ul><ul><li>Most 3 rd party carriers are requiring in the record! </li></ul><ul><ul><ul><li>What IUSO does is have a small check box at bottom of intake form. </li></ul></ul></ul>
  123. 123. Summary <ul><li>Before you leave the history we will review what we have recorded for the patient by saying: </li></ul><ul><li>1. “The reason for your visit is….” </li></ul><ul><li>(paraphrase the CC) </li></ul>
  124. 124. Summary <ul><li>2. Then review the signs and symptoms (Sx) of the CC and any positive (+) answers from the PMH, ROS or the FMH. </li></ul><ul><li>3. Repeat the medical allergies (KMA) and any Meds even if negative. </li></ul><ul><li>This way we are checking for a mistaken or confused answer that was given earlier. </li></ul>
  125. 125. Summary <ul><li>4. Then add: </li></ul><ul><li>“ Is there anything you would like to add that might have bearing on your eye care today?” </li></ul>
  126. 126. Summary <ul><li>With so many questions asked the patient may have forgotten to say something or you may have triggered something the patient thinks may be important but was waiting to be asked. </li></ul><ul><li>This allows them that opportunity. </li></ul>
  127. 127. References <ul><li>Bickley, L “Bates’s Guide to Physical Examination and History Taking” , 7 th 8th or 9th Ed. 1999, Lippincott, Chap 1 & 2. </li></ul>
  128. 128. *

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