History taking

history taking in optometry

1. History taking in optometry Sahibzada Hakim Anjum Nadeem Departmental Coordinator, Department of Optometry and Vision Sciences  CEO Anjum Eye Care & Optical Company Optometrist, Al-Khair Eye Hospital Lahore Co-Incharge OTTC, Optician, Refractionist, COAVS Email: [email protected]

2. What is History Taking Asking questions of patients to obtain information and aid diagnosis. Gathering data both objective and subjective for the purpose of generating differential diagnoses, evaluating progress following a specific treatment/procedure and evaluating change in the patient’s condition or the impact of a specific disease process.

3. “ Always listen to the patient they might be telling you the diagnosis”.

4. Key Principles of Patient Assessment It is estimated that 80% of diagnoses are based on history taking alone. Use a systematic approach. Practice infection control techniques. Establish a rapport with the patient. Ensure the patient is as comfortable as possible. Listen to what the patient says.

5. Ensure consent has been gained. Maintain privacy and dignity. Summarise each stage of the history taking process. Involve the patient in the history taking process. Maintain an objective approach. Ensure that your documentation (of the assessment) is clear, accurate and legible.

6. History taking in optometry History: A good history commonly leads to a diagnosis Helps you focus your examination Indicates when/what investigations are needed Helps determine the functional impact of the condition

7. History Demographic Data Presenting complaint History of presenting complaint Past ocular history Past medical history Drug History Family history Allergies Social history Review of Systems Summary of History Patient Questions/Feedback

8. Demographic DATA (Dd) Name A ddress P hone number Age G ender O ccupation R eligion M arital status H obbies  

9. Presenting Complaint(Pc) 1.Symptoms check - which symptoms should always be asked about ? i. Asthenopia ii. Headaches iii. Pain or burning iv. Diplopia v. Flashes and floaters - especially high myopes vi. Red eyes / Discharge vii. Itchy/ gritty eyes / dry eyes Adapt questions to patient's age e.g. driving/school board

10. 2.Distant Vision and Near Vision - possible causes of blurring i. constant DV blur - myopia ii. headaches caused by squinting iii. nuclear sclerosis  iv. intermittent DV blur - young diabetics v. variable myopia vi. pseudomyopia vii. intermittent NV blur - presbyopes viii. DV and NV blur - astigmatism ix. pathology e.g. cataract / maculopathy

11. History of presenting Complaint H ow should you question the patient about any complaints they have ? “LOFTSEA” What does LOFTSEA stand for?

12. L = location / laterality O = onset F = frequency / occurrence T = type and severity S = self treatment and its effectiveness E = effect on patient A = associated / secondary symptoms

13. LOFTSEA Location / Laterality Headache - where does it hurt Blurred vision - one or both eyes? near or distance? Diplopia - particular direction? Onset Sudden or Gradual? Gradual onset - suggests change in refractive status or cataract = less likely to be major concern Sudden changes - indicate pathology e.g. vascular problems / retinal detachment Frequency & Occurrence How often does it happen and for how long? e.g. highly hyperopic patient may report problems occur more during school, when reading but not so much during weekend

14. if it is a problem of visual origin, when do symptoms most likely occur? Reading , watching TV , driving , more during the week and less during weekends , start midday and gradually get worse Type & Severity headache - throbbing, sharp or dull? blurred vision - constant or intermittent? partial or total vision loss? diplopia - horizontal or vertical? disappear when close one eye? Self Treatment & its effectiveness does anything make it go away? if patient done nothing about it might be a minor problem

15. Effect on Patient Does it effect your everyday life? - less confident driving - can't see board at school - difficulty reading have you told your GP - if referral from GP write a reply even if no problems Associated OR Secondary Symptoms Any other difficulties? May or may not be associated with Chief Complaint

16. If the patient complains of pain, use the ' SOCRATES ' method of questioning; S ite: Unilateral/Bilateral O nset: When did it start, was it constant/intermittent, gradual/ sudden? C haracter:   What is the pain like e.g. sharp, burning, tight? R adiation: Does pain radiate/move anywhere? A ssociations: Is there anything else associated with the pain e.g. sweating, vomiting T ime course: Does it follow any time pattern, how long the eye has been red? E xacerbating/relieving factors: Does anything make it better or worse? S everity: How severe is the pain, consider using the 1-10 scale?

17. Past ocular history (poh) Ask about previous ophthalmological problems including :   P oor vision since birth or during childhood Refractive errors H istory of lazy eye/amblyopia R ecurrent ocular problems, particularly inflammatory (iritis) and herpes simplex keratitis P roblems associated with contact lens wear (e.g. bacterial keratitis). Check for overwear (using daily wear contact lenses for more than 1 day) and if the correct contact lens solution is used. 

18. Recent cataract surgery (to look for complications of surgery such as endophthalmitis, wound infection, intraocular lens displacement causing a sudden drop in visual acuity) Past or recent refractive/corrective eye surgery Previous history of trauma to the eye (associated with cataract, glaucoma, retinal detachment)

19. Past medical history (pmh)

20. Drug History (DH)

21. Family History (Fh) Enquire if there's a family history of any of these; Squint Glaucoma Cataracts Poor vision Amblyopia Refractive errors Ocular albinism and oculocutaneous albinism Diabetes Hypertension Juvenile macular dystrophies Cataract , Retinal / Corneal dystrophies , Retinal detachment

22. Birth history (BH) For children only: Prematurity Forceps delivery Low birth weight

23. Allergies Enquire if patient have known allergy to any drug e.g: Antibiotics Hay fever Any other medication

24. Social History (sh) Knowing  a patient’s occupation is relevant. If glasses are being prescribed you need to know what their occupation is. Do they work on a computer? Do they read? Are they at risk for eye injury? These type of questions help the ophthalmologist prescribe the correct glasses for the patient. Does the patent drink alcohol, smoke, use recreational drugs?

25. Review of systems (ros) Gather a short amount of information regarding the other systems in the body that are not covered in your History of Presenting Complaint (HPC). These are the main systems you should cover: Cardiovascular System Respiratory Gastrointestinal tract Neurology Genitourinary/renal Musculoskeletal Psychiatry ENT

26. Summary of history Complete your history by reviewing what the patient has told you. Repeat back the important points so that the patient can correct you if there are any misunderstandings or errors. You should also address what the patient thinks is wrong with them and what they are expecting/hoping for from the consultation. A good acronym for this is  ICE –   I deas,  C oncerns and  Ex pectations .

27. Patient questions/feedback During or after taking their history, the patient may have questions that they want to ask you. It is very important that you don’t give them any false information. As such, unless you are absolutely sure of the answer it is best to say that you will ask your seniors about this or that you will go away and get them more information (e.g. leaflets) about what they are asking. These questions aren’t necessarily there to test your knowledge, just that you won’t try and ‘blag it’.

28. When you are happy that you have all of the information you require, and the patient has asked any questions that they may have, you must thank them for their time and say that one of the doctors looking after them will be coming to see them soon.