1. Making the Most out of Patient History
Blair Lonsberry, MS, OD, MEd., FAAO
Professor of Optometry
Pacific University College of Optometry

2. Patient History
“There are five routes to the medical diagnosis-history, history, history, history and the physical examination.”
Tinsley R Harrison, MD

3. 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

4. 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?

5. Patient History 3 maxims must be heeded: 1. The history never ends
2. The history should be complete
3. Listen carefully to the patient

6. 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

7. 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.

8. 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?

9. 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

10. Case History: Elements
A comprehensive case history contains the following elements:
1. Chief complaint
2. Patient’s medical history
3. Medications and allergies
4. Visual and ocular history
5. Family eye and medical history
6. Vocational or recreational visual needs

11. Case History: 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

12. Case History: Chief Complaint
HPI: history of present illness.
Typically require 4 modifiers for each HPI which can include:
Location
Quality (e.g. sharp, dull, etc)
Quantity or severity (how bad is it?)
Timing (when? How long? How often?)
Setting (environmental factors, activities)
Factors making it better or worse
Associated manifestations

13. 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.

14. 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

15. Case History: Medical History
Many patients don’t see the connection between their systemic health and their eyes so will not mention them
Or if patient is currently medicated they don’t feel the condition is worth mentioning

16. Case History: Medical History
It is often necessary to ask patients about their medical history and give examples of conditions that you are interested in
E.g. “Do you have any health problems such as diabetes, hypertension, thyroid?”

17. 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

18. Case History: Medications and Allergies
Patients often think that because they are taking medications to control systemic diseases that it means those conditions don’t exist.
Not until you ask about their medications do you find out they have thyroid disease or hypertension
Many female patients don’t consider birth control pills as a medication

19. Case History: Medications and Allergies
Over the counter medications and supplements are also usually not considered by patients as “medications” because they are not prescription.
Important to find out if patient is allergic to any medications and if they have allergies in general to either foods or environmental

20. 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

21. Activities of Daily Living
Need to understand the patient’s daily world in order to assess if vision is impacting independence.
things that may not be on your normal optometric “radar”.
Dressing, grooming, cleaning, cooking, avocational activities, driving?…
Can the patient see details well enough to perform these ADLs?
Does visual field limitation impact these ADLs?
Ultimately determines what other professional services may be needed (Commission for the Blind, O&M instruction, etc.)

22. 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.

23. Case History: Family Eye and Medical History
Family Medical History:
Certain systemic diseases have a genetic predisposition
Diabetes
Hypertension
Cholesterol
Cancer

24. 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.

25. Case History: Psychosocial
Psychosocial History:
Alcohol?
Smoking?
Recreational drug use?
STD’s?

26. 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?

27. 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

28. 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

29. 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
Last A1C: 9.1

30. Blood Sugar
Throughout a 24 hour period blood sugar typically maintained between
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

31. Entrance Skills/Health Assessment
VA: OD: finger count OS: 20/40 CVF: OD: unable to assess OS: temporal hemianopsia Pupils: sluggish reactivity with a 2+ RAPD OD SLE: corneal arcus noted, no other significant findings IOP: 16, 16 mmHG OD, OS DFE: see photos
Note: not patient photos

32. 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

33. 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

34. Imaging/Surgery Referral
MRI revealed large mass in her brain
Patient was diagnosed with a Craniopharyngioma
She was referred for immediate surgery
Neurosurgeon reported that she removed a tangerine sized Craniopharyngioma
was the largest tumor she has ever removed
Note: not patient MRI

35. 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

36. 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)

37. 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.“

38. 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.

39. 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”

40. 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

41. Case History: Mental Status
During case history:
Assess level of consciousness,
General appearance
Affect
Ability to pay attention
Understand what is being said
Speak

42. 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

43. 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

44. The Effects of Eye Conditions

45. The Effects of Eye Conditions
A Corneal / Lens condition makes vision blurry and affects the ability to see objects with poor contrast.

46. The Effects of Eye Conditions
A Retinal condition affects high and low contrast visual acuity, making things blurry. Depending on the part of the retina affected, the central or peripheral visual fields can also be affected.

47. The Effects of Eye Conditions
If a person has a central field loss, the size of the object may need to be extremely large (i.e. large print) in order for it to be seen in the person's peripheral visual field.

48. The Effects of Eye Conditions
The object needs to be smaller so that it can be seen clearly in a person’s central field, if they have a peripheral field loss.

49. The Atypical Patient

50. 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

51. Disability Disabilities can be: Congenital/acquired Stable/progressive
Physical, cognitive, psychological, emotional, sensory, perceptual or behavioral
Communication is usually the most challenging aspect of dealing with patients with disabilities!!!!

52. 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.

53. 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.

54. 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

55. 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.

56. 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.

57. 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.

58. 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.

59. 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.

60. Thank You