Foundations Of Orth And Omt: Patient History Taking In Eye Care

Front 1

What things you should always do upon initially meeting the patient?

Back 1

- Introduce yourself & your role
- confirm identity of the patient

Front 2

How can you establish rapport with a patient?

Back 2

- listen
- don't be defensive
- stay on topic - caring
- no negative phrases
- put patient at ease

Front 3

(T/F) You have an ethical responsibility to the patient's privacy.

Back 3

True

Front 4

(T/F) You do not need permission from the patient to share information with family members.

Back 4

False - need permission

Front 5

Step 1: Chief complaint.
What should you ask?

Back 5

- onset of problem?
- duration of the problem - constant or intermittent?
- getting worse?
- any suspected cause?

Front 6

What should you ask about in regard to the patient's ophthalmic history?

Back 6

- any previous treatment for the problem?
- any previous surgery?
- wearing glasses?
- have you ever patched before?
- any previous eye conditions or injuries?
- exercises?
- any ocular medications? What and why?

Front 7

What should you ask about in regard to the patient's general health, if the patient is a child?

Back 7

- Birth history, including weight, term, forceps or O2 used, any complications?
- Meeting developmental milestones?
- seeing any other specialists in the hospital?

Front 8

What should you ask about in regard to the patient's general health, if the patient is an adult?

Back 8

- Any history of serious diseases or medical conditions?
- any accidents or trauma?

Front 9

What questions should be asked about family ophthalmic history?

Back 9

- any family members who had thick glasses while very young?
- glaucoma?
- early onset cataracts?
- strabismus?
- tumor?
- blindness?

Front 10

What specific diseases should you ask about when getting the patient's Family general health history?

Back 10

- Diabetes // Hypertension
- Thyroid problems
- High blood pressure
- Cancer
- MS

Front 11

(T/F) A patient who takes tylenol for headaches should be listed in the Meds section of the report.

Back 11

True

Front 12

Why is it important to ask about patient allergies?

Back 12

possible allergic conjunctivitis

Front 13

Give 8 important questions to ask of a patient who presents with strabismus.

Back 13

- Which way (in/out/up/down)?
- Which eye
- constant? intermittent?
- worse in certain gaze?
- worse at near/distance?
- ppt event?
- when did it start?
- sudden or gradual onset?
- any double vision?
- getting worse?
- ever rubbing or closing one eye?
- any treatment to date?
- if patching, how much?

Front 14

What should you ask if a patient has complaints about diplopia?

Back 14

- does it resolve upon occlusion of one eye?
- which way - images beside each other? on top? at an angle?
- worse in a certain gaze?
- worse at near/distance?
- actually double or just blurred?
- how long has it been present?
- constant or intermittent?
- had it before?
- ppt event?

Front 15

What are the important questions to ask a patient who has frequent headache?

Back 15

- how often?
- time of day?
- wake up with them?
- location of pain?
- type of pain?
- how severe?
- any visual auras?
- can usually resume daily activities?
- associated symptoms?
- family Hx of migraines?

Front 16

Important questions re: loss of vision?

Back 16

- near or distance?
- central or peripheral?
- worse in dim light?
- floaters?
- auras?
- gradual or sudden onset?
- ppt event?

Front 17

You ask a patient what brings them to the eye clinic that day, and they respond "one eye looks different." How can you define more specifically what the problem is?

Back 17

- Is one lid drooping? (variable?)
- Pupil size? (worse when?)
- pupil color? (early cataracts? eye cancer?)

Front 18

A patient has complaints of tearing and very watery eyes. What questions should you ask?

Back 18

- one eye or both?
- is the eye(s) red?
- clear or purulent discharge?
- light sensitivity?
- large eyes?
- cloudy cornea?

Front 19

Patient complains of pinkeye. What could you ask to define this more specifically?

Back 19

- one or both eyes?
- any charge? what color?
- itching?
- associated pain?
- blurred vision or light sensitivity?

Front 20

What is a hyphema? What is it caused by? What should you ask? What should you advise the patient to do?

Back 20

- Hyphema is a pool of blood within the anterior chamber, caused by blunt trauma.
- ASK: what he/she does for quiet activity? ppt event?????
- ADVISE: NO ASPIRIN. No vigorous activity. Tylenol and med drops.

Front 21

A patient mentioned that they have diabetes. What specific questions would you ask then?

Back 21

- When were you diagnosed?
- Are your sugars well controlled?
- any double vision or fluctuations in vision?
- spots or floaters?

Front 22

A patient mentions JRA - juvenile rheumatoid arthritis. What hould you ask then?

Back 22

- age of onset?
- number of joints involved?
- pain or photophobia?

Front 23

You are examining a 4 year old child whose mother mentions prematurity of birth. What specific points do you now need to address?

Back 23

- gestational age?
- forceps required?
- O2 required?
- birth weight?
- ROP?

Front 24

A patient is currently using steroids, either ocularly or for another medical condition. What do you need to know about the usage of steroids?

Back 24

- When did you start? How long did you use them for?
- How many times have they been on a steroid cycle?
- dosage?
- tapering?

Front 25

4 year old male presents with Hx of L inward turn for the past year.

Back 25

- Which eye? (L)
- started when? (1 yr)
- constant or intermittent? (started (T) but now manifest)
- ppt event? (no)
- closing or rubbing one eye? (no)
- double vision? (no)
- associated pain? (no)
- any previous/current treatment? (glasses for past 3 mo)
- do the glasses resolve the turn? (no)
- any previous ocular problems? patching? exercises? surgery? (no)

GH? good Meds? puffer prn
All? N/A BH? FTND
Fam Hx: uncle- strabismus, cousin- congenital cataract. NEG- glaucoma, blindness.
NEG- thyroid, diabetes, heart dis

Front 26

38 year old female has an outward turn and wants it fixed.

Back 26

- Which eye? (O.S.)
- Onset? (birth had ET and surgery to fix; started to have X about 10 yrs ago)
- constant or (T)? (constant)
- getting worse? (yes - turning further)
- double vision? (no)
- current treatment? (exercise - pen pushups - no effect)

GH? good Meds? Echinaecia All? pollen
Fam Hx? cousin- strab GM- diabetes. NEG- thyroid, heart dis, cancer

Front 27

50 year old male has double vision

Back 27

- When did it start? (July 9, 2003)
- sudden or gradual? (sudden - woke up with it)
- how are the images displaced? (horizontally)
- resolve upon occlusion of one eye? (yes)
- constant or (T)? (constant)
- worse on certain gaze? (worse on L gaze)
- ppt event? (no)
- Hx of trauma or infection? (no)
- Ever had it before? (no)
- Any previous eye problems? (glasses since age 23)
- current treatment? (Fresnel prism on glasses - needs prism to see singly in any gaze)

GH- diabetes, Dx? 42, controlled
Meds? Insulin All? penicillin
Fam Hx? Father- diabetes, HBP. Mother- breast cancer. NEG- Thyroid