lecture 3

V550V550

The History QuestionsThe History Questions

Richard E. Meetz, OD, MSRichard E. Meetz, OD, MS

20092009

The Working Phase:The Working Phase:

Setting up the recordSetting up the record

1.1. Date and timeDate and time

2.2. DemographicsDemographics

3.3. Review patient’s intake formReview patient’s intake form

4.4. Review patient’s previous examsReview patient’s previous exams

Date and TimeDate and Time

The The full datefull date must be on every must be on every

record!record!– Month / day / yearMonth / day / year

– The month and day The month and day withoutwithout the year the year

is a record lostis a record lost to time; to time;

just when did it happen?just when did it happen?


Time should appear:Time should appear:

1.1. Early in the examination (start)Early in the examination (start)2.2. With any application of With any application of

pharmaceutical dropspharmaceutical drops3.3. With any test where time is a With any test where time is a

variable - variable - Example pressures: IOPs, Example pressures: IOPs, BPs, etc.BPs, etc.

4.4. At the start of any treatment At the start of any treatment procedureprocedure


12 vs 24 hour clock? 12 vs 24 hour clock?

– Not critical as long as reader can Not critical as long as reader can tell morning from afternoon.tell morning from afternoon.

DemographicsDemographics

Name: Last Name, first name & middle Name: Last Name, first name & middle initialinitial– Must be on every page of record!Must be on every page of record!

Age, Age, Date of BirthDate of Birth (DOB) and Place of (DOB) and Place of BirthBirth

Sex, Marital status, Race or Ethnic Sex, Marital status, Race or Ethnic groupgroup

Address and Telephone numbers Address and Telephone numbers – both work & home, (cell?)both work & home, (cell?)

SSN’s and Insurance Co. #’sSSN’s and Insurance Co. #’s VocationVocation

What Questions to Ask?What Questions to Ask?

The series of questions and The series of questions and order will depend on the type order will depend on the type of examination.of examination.– Comprehensive vs problem Comprehensive vs problem orientatedorientated

In this class and those in 2nd In this class and those in 2nd year, we will concentrate on year, we will concentrate on the Comprehensive History.the Comprehensive History.


Always keep in mind that there Always keep in mind that there is a reason for every question is a reason for every question we will ask.we will ask.

Know it!Know it!

Be able to explain it to the Be able to explain it to the patient.patient.

IN LAY termsIN LAY terms


The order needs to be logical!The order needs to be logical!– For both the clinician and the For both the clinician and the patient.patient.

DO NOT JUMP AROUND!DO NOT JUMP AROUND!From one Sx to the nextFrom one Sx to the nextFrom CC to Sx to POHx to PMHx to their From CC to Sx to POHx to PMHx to their ROS to the family’s medical Hx etc.ROS to the family’s medical Hx etc.

– The question just asked needs to help The question just asked needs to help the patient answer the next.the patient answer the next.

The Reason for Seeking CareThe Reason for Seeking Care

The Reason for Visit (RFV)The Reason for Visit (RFV)– Can be for a vision complain (CC)Can be for a vision complain (CC)

refractive refractive healthhealth

– Routine exam Routine exam new patientnew patientwell checks (Ins, job req, application)well checks (Ins, job req, application)

– Doctor recommended returnDoctor recommended returnOne year glaucoma suspect, cataract One year glaucoma suspect, cataract check check


The Reason for Visit (RFV)The Reason for Visit (RFV)– ““The coverage of services rendered The coverage of services rendered (payment of fees) is dependent on (payment of fees) is dependent on the purpose of the examination the purpose of the examination rather than the ultimate diagnosis rather than the ultimate diagnosis of the patient’s condition” - CMSof the patient’s condition” - CMS


The Reason for Visit (RFV)The Reason for Visit (RFV)– Chief complain (CC)Chief complain (CC)

““Is a concise statement describing the Is a concise statement describing the symptom, problem, condition, diagnosis, symptom, problem, condition, diagnosis, physician recommended return or other physician recommended return or other factor that is the reason for the factor that is the reason for the encounter, usually stated in the encounter, usually stated in the patient’s words”- CMS Manualpatient’s words”- CMS Manual


The Reason for Visit (RFV)The Reason for Visit (RFV)– Routine exams that are not covered Routine exams that are not covered by CMSby CMSFor the purpose of prescribing, fitting For the purpose of prescribing, fitting or changing eyeglasses, contact lensesor changing eyeglasses, contact lenses

Examination performed without Examination performed without relationship (no CC) to treatment or relationship (no CC) to treatment or diagnosis for a specific illness, diagnosis for a specific illness, symptom complaint or injurysymptom complaint or injury

Well checks for 3rd partiesWell checks for 3rd parties– Insurance Co, job applicationInsurance Co, job application

The CMSThe CMS

The Centers for Medicare & Medicaid The Centers for Medicare & Medicaid ServicesServices– Federal agency responsible for Federal agency responsible for management and oversight of both management and oversight of both Medicare & Medicaid ServicesMedicare & Medicaid Services

– Sets rules and regulations for fed Sets rules and regulations for fed reimbursable health carereimbursable health careEvaluation and Management Service Codes Evaluation and Management Service Codes “E/M” codes“E/M” codes

Followed by most 3rd party payersFollowed by most 3rd party payers


Chief Complaint: CCChief Complaint: CC

– Ask an open-ended questionAsk an open-ended question

Example:Example: “ “What is the reason for this What is the reason for this visit” visit” oror

““What problems/symptoms bring What problems/symptoms bring you to the office today?”you to the office today?”


Chief Complaint (cont’d)Chief Complaint (cont’d)Record statement in the patient’s Record statement in the patient’s own words “in quotations”.own words “in quotations”.

““I have been having blurred vision I have been having blurred vision when I’m driving my car”when I’m driving my car”May shorten somewhat, but do not change May shorten somewhat, but do not change meaning.meaning.

Telegraphing: “blurred vision when Telegraphing: “blurred vision when driving”driving”

The Reason for Seeking CareThe Reason for Seeking CareHistory of present Illness: HPIHistory of present Illness: HPI The goal of the HPI is to develop a The goal of the HPI is to develop a Working DiagnosisWorking Diagnosis of the patient’s of the patient’s problem (CC).problem (CC).– The clinician must clearly understand The clinician must clearly understand the patients CC and symptoms(Sx) in the patients CC and symptoms(Sx) in order to solve them.order to solve them.

– The HPI is a series of follow-up The HPI is a series of follow-up questions designed to help the questions designed to help the historian historian

History of Present Illness (HPI)History of Present Illness (HPI)

LocationLocation QualityQuality SeveritySeverity DurationDuration TimingTiming

ContextContext Associated Associated signssigns

Modifying Modifying factorsfactors

SymptomsSymptoms

For the HPI, questions are For the HPI, questions are asked of the following 9 Sx asked of the following 9 Sx characteristics:characteristics:

History of Present Illness (HPI)History of Present Illness (HPI)NOTENOTE: : You do not need to ask all 9 You do not need to ask all 9 questions, only as many needed to questions, only as many needed to understand the CC.understand the CC.

BUT you BUT you mustmust address at least 4 of address at least 4 of them them AND RECORD THEMAND RECORD THEM for the extended for the extended history of present illness requirement history of present illness requirement for a comprehensive exam (CMS).for a comprehensive exam (CMS).

Most Common History Pitfall:Most Common History Pitfall:

Not fully questioning the patient Not fully questioning the patient about the HPI.about the HPI.ReasonsReasons::

Thinking you understand the patientThinking you understand the patientRush to get into objective part of Rush to get into objective part of the examinationthe examination

Patient is not a good historianPatient is not a good historianPatient in a rush to read the eye Patient in a rush to read the eye chartchart

Most Common History Pitfall:Most Common History Pitfall:

By not understanding the CC, you By not understanding the CC, you will spend too much time doing will spend too much time doing unnecessary testing or end up unnecessary testing or end up not solving the CC.not solving the CC.

Fully understanding the CC is a Fully understanding the CC is a MUSTMUST!!

2nd Most Common History 2nd Most Common History Pitfall:Pitfall:

Not recording enough details of the Not recording enough details of the HPI to support the level of care.HPI to support the level of care.– For a comprehensive exam there must For a comprehensive exam there must be 4 HPI following the CCbe 4 HPI following the CC

– For a intermediate or problem focus For a intermediate or problem focus (level 2) there needs to be 1-3 F/U (level 2) there needs to be 1-3 F/U questions of the HPIquestions of the HPI

– Without documentation of the F/U Without documentation of the F/U questions exams are downgraded with questions exams are downgraded with less reimbursement less reimbursement

Most Common Missed Most Common Missed Question:Question:

Which eye or both?Which eye or both?

Recording the CC & HPIRecording the CC & HPI

Recorded in short words and Recorded in short words and phrasesphrases

Example:Example: After the CC, After the CC, Patient says “The blurred vision has Patient says “The blurred vision has been happening for the last two been happening for the last two months,I notice it late at night or months,I notice it late at night or when driving on the highway, and I when driving on the highway, and I can’t read the green signs until I can’t read the green signs until I get almost on top of them.”get almost on top of them.”


You recordYou record::

CC: “blurred vision when driving”, CC: “blurred vision when driving”, late night or highway signs X 2 late night or highway signs X 2 monthsmonths


– If patient’s RFV has no CC, then If patient’s RFV has no CC, then hold off recording ‘routine’ until hold off recording ‘routine’ until end.end.

May find problem later on in the exam.May find problem later on in the exam.

If not reported yet, ask next about If not reported yet, ask next about distance and near vision with distance and near vision with their Rx, if worn, before you are their Rx, if worn, before you are finished with the CC/HPI area.finished with the CC/HPI area.

Hx mnemonicsHx mnemonics

A mnemonic is a word or words A mnemonic is a word or words that serve as a memory trigger that serve as a memory trigger for remembering steps or parts for remembering steps or parts of of

The are 3 that you will find useful The are 3 that you will find useful for symptom analysis questionsfor symptom analysis questions– TADDTADD– OPQRSTOPQRST– OLD CARTSOLD CARTS

TADDTADD Used for F/U of allUsed for F/U of all 2° Sx2° Sx

– TTime of onset: 1ime of onset: 1stst date date andand time of day time of day– AAssociation: aggravating factors or ssociation: aggravating factors or activity when noticedactivity when noticed

– DDuration: how long it lasts/how oftenuration: how long it lasts/how often– DDescription/severityescription/severity

These are the minimum # questions that These are the minimum # questions that must be asked of must be asked of all positive symptomsall positive symptoms from the patient.from the patient.

Beyond TADDBeyond TADD

NOTE!NOTE! TADD is TADD is only the bare minimumonly the bare minimum f/u for any Sx.f/u for any Sx.

You are not locked into TADD; You are not locked into TADD; you should expand your you should expand your questioning when the symptoms questioning when the symptoms warrant.warrant.

Beyond TADDBeyond TADDOPQRSTOPQRST Is a mnemonic for a better set Is a mnemonic for a better set of symptom analysis questions;of symptom analysis questions;

O= OnsetO= Onset

P= Provocative/PalliativeP= Provocative/Palliative

Q= Quality/QuantityQ= Quality/Quantity

R= Region/RadiationR= Region/Radiation

S= Severity/ScaleS= Severity/Scale

T= Timing ( frequency, duration)T= Timing ( frequency, duration)

OPQRSTOPQRSTO= OnsetO= Onset

– Onset; when did it begin?Onset; when did it begin?Day, weeks, months ago?Day, weeks, months ago?Time of day, AM or PM?Time of day, AM or PM?

P= provocative/palliativeP= provocative/palliative– What causes the symptom?What causes the symptom?– What makes it better or worse?What makes it better or worse?

OPQRSTOPQRSTP= P=

– Provocative= What makes it worse?Provocative= What makes it worse?– Palliative = What makes it better?Palliative = What makes it better?

Q= Quality /QuantityQ= Quality /Quantity– How does it feel, look, sound?How does it feel, look, sound?– How bad is it now? Relative to How bad is it now? Relative to previous times?previous times?

– Can you keep up with your usual Can you keep up with your usual activities?activities?

OPQRSTOPQRST

R= Region/RadiationR= Region/Radiation– Where does it occur?Where does it occur?– Does it radiate?Does it radiate?– Does it change?Does it change?

S= Severity/ScaleS= Severity/Scale– How bad is it?How bad is it?– On a scale of 1-10 with 10 being On a scale of 1-10 with 10 being the worst….the worst….1 to 5 better!1 to 5 better!

OPQRSTOPQRSTT= Timing T= Timing

– Time of day, AM or PM?Time of day, AM or PM?

– Gradual or abrupt?Gradual or abrupt?

– Frequency; How often? Frequency; How often? (Daily, weekly, monthly etc)(Daily, weekly, monthly etc)

– Duration; How long?Duration; How long?Constant or intermittent?Constant or intermittent?

OLD CARTSOLD CARTS Is a mnemonic similar to OPQRST;Is a mnemonic similar to OPQRST;

O= OnsetO= Onset

L= LocationL= Location

D= DurationD= Duration

C= CharacterC= Character

A= Aggravating/alleviating FactorsA= Aggravating/alleviating Factors

R= Region/RadiationR= Region/Radiation

T=TimingT=Timing

S= Severity/ScaleS= Severity/Scale

Medical ChartingMedical ChartingRecording in the medical chartRecording in the medical chart

In the busy medical office, there is a need In the busy medical office, there is a need for speed & to shorten record keeping.for speed & to shorten record keeping.

Information, especially patient history and Information, especially patient history and review of systems (ROS) are not and could review of systems (ROS) are not and could not be recorded verbatim.not be recorded verbatim.

Health care providers use the technique of Health care providers use the technique of “Telegraphing”“Telegraphing”

Medical ChartingMedical ChartingRecording in the medical Recording in the medical chartchart

““Telegraphing”Telegraphing”– A technique of shortening chart entries A technique of shortening chart entries

by deleting all extraneous words.by deleting all extraneous words.

“ “a, the, ands” etc.a, the, ands” etc.

But not so much that meaning is lost.But not so much that meaning is lost.

Medical ChartingMedical Charting

““Telegraphing”Telegraphing”Example: full wording Example: full wording

The patient denies that he has had any The patient denies that he has had any drainage from his left eye. He also drainage from his left eye. He also says that he has noticed no redness, says that he has noticed no redness, has no tearing, has experienced no has no tearing, has experienced no photophobia nor does he have any pain photophobia nor does he have any pain in that eye.in that eye.

5 lines, 38 words5 lines, 38 words


““Telegraphing”Telegraphing”Example: telegraphedExample: telegraphed

Patient denies any drainage, redness, Patient denies any drainage, redness, tearing, photophobia or pain in left tearing, photophobia or pain in left eye.eye.

2 lines, 12 words2 lines, 12 words


Recording the Chief ComplaintRecording the Chief Complaint

The CC must be in the patients The CC must be in the patients own words! own words!

Placed in “Quotes”Placed in “Quotes” – In the CC no words are changed!In the CC no words are changed!– But may be telegraphedBut may be telegraphed

Medical ChartingMedical ChartingRecording the Chief ComplaintRecording the Chief Complaint Example: full wordingExample: full wording

– Patient reports “when I’m driving those Patient reports “when I’m driving those green highway signs are hard to read at green highway signs are hard to read at night”night”

– You record You record CC: “green highway signs hard CC: “green highway signs hard to read at night” to read at night”

– Do not record:Do not record:CC: “signs hard to read” or CC: “signs hard to read” or CC: “Patient reports blur at night”CC: “Patient reports blur at night”

Medical ChartingMedical ChartingRecording the Chief ComplaintRecording the Chief Complaint Bad Examples:Bad Examples:

( from the Jo of Court Reporting)( from the Jo of Court Reporting)

– Patient has chest pain if she lies on her Patient has chest pain if she lies on her left side for over a year.left side for over a year.

– The patient is tearful and crying The patient is tearful and crying constantly. She also appears to be constantly. She also appears to be depressed.depressed.

– When she fainted her eyes rolled around the When she fainted her eyes rolled around the room.room.

– She has had no rigors or shaking chills, She has had no rigors or shaking chills, but her husband states she was very hot in but her husband states she was very hot in bed last night.bed last night.

Medical ChartingMedical ChartingRecording the Chief ComplaintRecording the Chief Complaint Bad Examples:Missing words?Bad Examples:Missing words?

( from the Jo of Court Reporting)( from the Jo of Court Reporting)

– Bleeding started in the rectal area and Bleeding started in the rectal area and continued all the way to LA.continued all the way to LA.

– She stated that she had been constipated She stated that she had been constipated for most of her life until 1989 when she for most of her life until 1989 when she got a divorce.got a divorce.

– The patient states there is a burning pain The patient states there is a burning pain in his penis, which goes to the floor.in his penis, which goes to the floor.

– The patient has no past history of The patient has no past history of suicides.suicides.

Medical ChartingMedical ChartingRecording the Chief ComplaintRecording the Chief Complaint Bad Examples:Conflicts!Bad Examples:Conflicts!

(from the Jo of Court Reporting)(from the Jo of Court Reporting)

– Occasional, constant, infrequent Occasional, constant, infrequent headaches.headaches.

– Patient was alert and unresponsive.Patient was alert and unresponsive.

– The skin was moist and dry.The skin was moist and dry.

– Healthy appearing decrepit 69 year-old Healthy appearing decrepit 69 year-old male, mentally alert but forgetful.male, mentally alert but forgetful.

SymptomatologySymptomatology

Is the art of recognizing Is the art of recognizing the classical symptoms of the classical symptoms of diseases and disorders and diseases and disorders and how patients typically how patients typically describe themdescribe them

Common Refractive SxCommon Refractive Sx

1. Hyperopia1. Hyperopia – “Far sighted” – not enough – “Far sighted” – not enough power or eye is too short. Patient can power or eye is too short. Patient can accommodate to clear the distance, but accommodate to clear the distance, but then has to focus more to see near.then has to focus more to see near.

CC: No distance or near blur but will CC: No distance or near blur but will complain of: complain of: “eye strain”“eye strain”

School age to 50’sSchool age to 50’s Late in day or after near tasksLate in day or after near tasks


2.Myopia2.Myopia – “Near sighted” – Too much – “Near sighted” – Too much power or eye is too long. Eyes power or eye is too long. Eyes are focus for near.are focus for near.

CC isCC is “ “Distance blur and clear up close”Distance blur and clear up close”

School age to 20’s School age to 20’s Constant, worse at night, Constant, worse at night,

squinting helpssquinting helps

Common Refractive SxCommon Refractive Sx3. Astigmate3. Astigmate – Warpage of cornea – Warpage of cornea

causing a slight blur or “double” causing a slight blur or “double” image at all distances.image at all distances.

CC: CC: ““Blur or shadow around letters” or Blur or shadow around letters” or “ghost images”“ghost images” and even monocular double and even monocular double visionvision

School age to 40’sSchool age to 40’s All distances but most noticeable at All distances but most noticeable at

near or on video screensnear or on video screens


4. Presbyopia4. Presbyopia – Loss of near focus as – Loss of near focus as part of normal aging. Can occur part of normal aging. Can occur with any of the above refractive with any of the above refractive errors.errors.

CC: CC: Complains of eye strain, loss of Complains of eye strain, loss of close reading, difficulty in dim close reading, difficulty in dim light and/or light and/or “arms are too short”“arms are too short”

Adult age 39 and upAdult age 39 and up Stable after age 54 and upStable after age 54 and up

Common Binocular SxCommon Binocular Sx

5. Accommodative Dysfunction5. Accommodative Dysfunction – – inability to hold clear near vision inability to hold clear near vision or a spasm of near focus in under or a spasm of near focus in under 35 yo.35 yo.

CC: CC: “Words blur after 10 to 20 min of “Words blur after 10 to 20 min of

near work with HAs & distance blur near work with HAs & distance blur

after reading.”after reading.”


Accommodative DysfunctionAccommodative Dysfunction Typically school age to mid 20’sTypically school age to mid 20’s Most notable at near or on video Most notable at near or on video

screens, but may see distance screens, but may see distance blur after readingblur after reading– Either will have to hold closer to Either will have to hold closer to

read orread or Accommodative spasmAccommodative spasm

– Will have to push awayWill have to push away Accommodative insufficiencyAccommodative insufficiency

Watch for side effects of Watch for side effects of medicationmedication– Many cause accommodation problemsMany cause accommodation problems

Common Binocular SxCommon Binocular Sx6. Binocular Dysfunction/Vergence 6. Binocular Dysfunction/Vergence

DysfunctionDysfunction – Extra ocular muscle’s – Extra ocular muscle’s inability to hold single clear vision.inability to hold single clear vision.

CC: CC: “Double vision at night”, “Double vision at night”, ““Double vision when reading”Double vision when reading” ““Discomfort around eyes”, Discomfort around eyes”, ““Words run together or move during Words run together or move during

reading”, reading”, ““Skipping lines when reading or loss Skipping lines when reading or loss

of place”of place”


Binocular Dysfunction/Vergence Binocular Dysfunction/Vergence Dysfunction (cont’dDysfunction (cont’d))

School age to 40’s School age to 40’s Most notable at near or video Most notable at near or video screens, but may see distance screens, but may see distance complaints at night, complaints at night, intermittentintermittent

Adjusted postures commonAdjusted postures common– headtiltheadtilt

Common Ocular SxCommon Ocular Sx

7. Optical Quality/ Optical 7. Optical Quality/ Optical DistortionDistortion – Loss of sharp optic transmission due Loss of sharp optic transmission due

to degrading of tears, cornea or lens.to degrading of tears, cornea or lens.

CC: CC: – ““Difficulty with glaring lights” orDifficulty with glaring lights” or

– ““Constant or occasional distance blur” Constant or occasional distance blur”

– ““decrease in night vision”decrease in night vision”

– ““Halos or rings around lights”Halos or rings around lights”

Common Ocular SxCommon Ocular SxOptical Quality/Distortion (cont’d)Optical Quality/Distortion (cont’d)

40 y.o. and up 40 y.o. and up

CL wearersCL wearers

Often with Sx of burning or dry eyesOften with Sx of burning or dry eyes– With allergy SxWith allergy Sx

Often at distance after video screen task or Often at distance after video screen task or

drivingdriving

If fluctuation in vision think tears (Sx If fluctuation in vision think tears (Sx

over a few min)or Diabetes(fluctuation day over a few min)or Diabetes(fluctuation day

to day)to day)

If constant think cornea or lens (cataract)If constant think cornea or lens (cataract)


8. Diplopia8. Diplopia – Symptoms of double – Symptoms of double vision, can be binocular vision, can be binocular (vergence or neurologic) or (vergence or neurologic) or monocular (optical or retinal)monocular (optical or retinal)

CC: CC: “ghost images” or “ghost images” or – ““lights double at night”lights double at night”


DiplopiaDiplopia (cont’d) (cont’d)Any age, Sx clear-cut or vagueAny age, Sx clear-cut or vagueSx may be persistent or Sx may be persistent or intermittentintermittent

Older pts CC of monocular diplopia: Older pts CC of monocular diplopia: 2° to cataracts2° to cataracts

Older pts CC binocular diplopia: Older pts CC binocular diplopia: decompensating vertical phoriadecompensating vertical phoria

Sudden onset on any incomitant Sudden onset on any incomitant binocular Sx: neurologicbinocular Sx: neurologic


9. Photopsia9. Photopsia – Spontaneous flash – Spontaneous flash or spark of light or slow or spark of light or slow flicking streaks or spectrums.flicking streaks or spectrums.

CC: CC: – ““saw a light bulb flash” or saw a light bulb flash” or – ““zig-zag lines” zig-zag lines” – ““Blue streaks at night”Blue streaks at night”– ““stars or sparkles”stars or sparkles”


PhotopsiaPhotopsia (cont’d) (cont’d)Any age (teens and up)Any age (teens and up)Assoc. S&S of HTN, HA, trauma, Assoc. S&S of HTN, HA, trauma, retinal detachment, stroke, retinal detachment, stroke, vertigovertigo

Can be short (Vitroretinal) or Can be short (Vitroretinal) or long (20 min. Vascular)long (20 min. Vascular)

Most common Vitroretinal cause Most common Vitroretinal cause is floatersis floaters

Most common Vascular cause is Most common Vascular cause is MigraineMigraine

Common Ocular SxCommon Ocular Sx10. Ocular Discomfort10. Ocular Discomfort – Sx vary from – Sx vary from

asthenopia to compelling pain asthenopia to compelling pain arising or localizing in the eye arising or localizing in the eye or peri-ocular tissues.or peri-ocular tissues.

CC: CC: “ache around my eye” or“ache around my eye” or

– ““irritation or burning”irritation or burning”

– ““pain when I blink”pain when I blink”

– ““lights hurt my eyes”lights hurt my eyes”


Ocular Discomfort (cont’d)Ocular Discomfort (cont’d)– Often with other S&S of redness, Often with other S&S of redness, tearing, HAs, FBstearing, HAs, FBs

– Often assoc. with refractive errors, Often assoc. with refractive errors, vergences, lighting, time at near vergences, lighting, time at near tasks, stress, allergiestasks, stress, allergies

– Most common ache around eyes: sinus Most common ache around eyes: sinus or teethor teeth

– Most common irritation or burning: Most common irritation or burning: dry eyesdry eyes

Common Ocular SxCommon Ocular Sx11. Red eyes11. Red eyes – Increased – Increased

visibility of conjunctival visibility of conjunctival vessels. Sx range from a mild vessels. Sx range from a mild sting or irritation to sting or irritation to compelling pain and nausea.compelling pain and nausea.

CC: “Eye turned blood red” or CC: “Eye turned blood red” or – ““road map eyes”road map eyes”– ““lids stuck together”lids stuck together”– ““dry and burning eyes”dry and burning eyes”


Red eyesRed eyes (cont’d) (cont’d)Any ageAny ageOften with allergies, CL, Often with allergies, CL, exposure, infections, medications, exposure, infections, medications, pollutants, trauma, uveitispollutants, trauma, uveitis

Most common in young: Most common in young: conjunctivitis “pink eye”conjunctivitis “pink eye”

Most common in adults: dry Most common in adults: dry eyes/poor tearseyes/poor tears


12. Halos or rays12. Halos or rays – Reports of rings – Reports of rings around light or streaks shooting around light or streaks shooting out of lights at night. Due to out of lights at night. Due to edema or Hedema or H22O in the cornea or O in the cornea or lens. lens. (See also “Optical Quality/Distortion”)(See also “Optical Quality/Distortion”)

CC: “Halos or rings around CC: “Halos or rings around lights”, “Difficulty with glaring lights”, “Difficulty with glaring lights” or “Lights look like lights” or “Lights look like shooting stars”shooting stars”


Halos or rays (cont’d)Halos or rays (cont’d)

Contact lens wearers and Contact lens wearers and Older personsOlder persons

Assoc. with glaucoma, corneal Assoc. with glaucoma, corneal degeneration, cataracts, DMdegeneration, cataracts, DM

If younger, think corneal/tearsIf younger, think corneal/tears If older, think lens (cataract)If older, think lens (cataract)


13. Photophobia13. Photophobia – Abnormal – Abnormal sensitivity to light. sensitivity to light.

* Ocular pain with light.* Ocular pain with light.

CC:CC:– “ “Have to wear sunglasses when I Have to wear sunglasses when I

go out in daylight”go out in daylight”– ““I can’t open my eyes up in the I can’t open my eyes up in the

light”light”– ““lights make my eyes water”lights make my eyes water”– ““on coming car lights are painful”on coming car lights are painful”


Photophobia (cont’d)Photophobia (cont’d)

Any age, most often young, blue Any age, most often young, blue eyes (idiopathic)eyes (idiopathic)

Often with infections, Often with infections, medications, trauma, medications, trauma, uveitisuveitis


Photophobia (cont’d)Photophobia (cont’d)Important F/U question for a Important F/U question for a Photophobia patientPhotophobia patient

““Does the eye hurt when it is Does the eye hurt when it is covered and a light is shown into covered and a light is shown into the other eye?”the other eye?”

If “yes” think uveitisIf “yes” think uveitis


14. Vision Loss14. Vision Loss – Diminution of – Diminution of vision in part or all of the vision in part or all of the visual field in one or both visual field in one or both eyes. Constant or episodic eyes. Constant or episodic visual disturbances. visual disturbances. Gradual or sudden.Gradual or sudden.

CC: “Can’t see out of one CC: “Can’t see out of one eye”, “having vision spells”, eye”, “having vision spells”, “can’t see to one side”, “hole “can’t see to one side”, “hole in the center of my vision”in the center of my vision”


Vision Loss (cont’d)Vision Loss (cont’d)Older patients but can be teens and Older patients but can be teens and

upupOften with other S&S of cataracts, Often with other S&S of cataracts,

CHD/CVD, HTN, HA, migraine, trauma, CHD/CVD, HTN, HA, migraine, trauma,

TIA, stroke, smoking, vertigo, etc.TIA, stroke, smoking, vertigo, etc.Episodic may last minutes to hours, Episodic may last minutes to hours,

think vascularthink vascularGradual constant loss most often Gradual constant loss most often

retinal or opticalretinal or optical


15. Headache15. Headache – Reports of pain – Reports of pain discomfort around, top of, discomfort around, top of, through, under the head. See through, under the head. See also above symptoms.also above symptoms.

CC: CC: “Headache”“Headache”

Children and upChildren and up

Headache (cont’d)Headache (cont’d)– Assoc. with Assoc. with many symptoms and etiologiesmany symptoms and etiologiesSymptomsSymptoms TypeTypePainPain SinusSinusNauseaNausea MigraineMigrainePhotophobiaPhotophobia ClusterClusterHTNHTN CNS Bleeds (Strokes)CNS Bleeds (Strokes)Visual LossVisual Loss HTNHTNCongestionCongestion AsthenopiaAsthenopiaFatigueFatigue Tension (muscle)Tension (muscle)HemiparesisHemiparesis HypoglycemicHypoglycemicVertigoVertigo Giant Cell arteritisGiant Cell arteritisFeverFever TMJTMJDepressionDepression TumorTumorPhotopsiaPhotopsia Cranial BleedsCranial BleedsScalp tendernessScalp tenderness ConcussionConcussionTearingTearing Toxic (drug)Toxic (drug)VomitingVomiting GlaucomaGlaucomaNeck StiffnessNeck Stiffness MeningitisMeningitis

Back to the Hx:Back to the Hx: DemographicsDemographicsCCCC

– OPQRSTOPQRST

Distance and near blurDistance and near blur 2° Visual Symptoms and HA2° Visual Symptoms and HA POHxPOHx PMHxPMHx ROS and family MHxROS and family MHx SHx SHx

2° complaints / Sx2° complaints / Sx

Next ask about 2° Visual Next ask about 2° Visual Symptoms and HA’s:Symptoms and HA’s:

Ask RE:Ask RE:– Diplopia Diplopia – HalosHalos– Flashes of lightsFlashes of lights– FloatersFloaters– SeizuresSeizures– HeadachesHeadaches

2° Visual Symptoms2° Visual Symptoms

Ask RE: Diplopia “Double Vision”Ask RE: Diplopia “Double Vision”– If (+) ask Monocular vs BinocularIf (+) ask Monocular vs Binocular

““Shadows or true double vision?”Shadows or true double vision?”

Ask RE: Halos “Rings around Ask RE: Halos “Rings around lights”lights”– With or with out Rx?With or with out Rx?– R/O Glaucoma vs Corneal R/O Glaucoma vs Corneal Degeneration, Cataracts or EdemaDegeneration, Cataracts or Edema

2° Visual Symptoms2° Visual Symptoms Ask RE: Photopsia “Flashes of lights”Ask RE: Photopsia “Flashes of lights”

– If (+) ask length of time the lights If (+) ask length of time the lights appear;appear;

short flash (1 to 3 seconds) = Retinal vs short flash (1 to 3 seconds) = Retinal vs

Longer flash (1/2 min to 30 min) = vascular)Longer flash (1/2 min to 30 min) = vascular)

Ask RE: “Floaters” New or changesAsk RE: “Floaters” New or changes Ask RE: “Seizures” Hx or under careAsk RE: “Seizures” Hx or under care

““TADD” for each positive Sx.TADD” for each positive Sx.

2° Visual Symptoms2° Visual Symptoms

Next ask about: “Headaches”Next ask about: “Headaches”

– If patient is positive for If patient is positive for headaches then proceed to the HA headaches then proceed to the HA line of questions.line of questions.

Headache Hx:Headache Hx:

1. Location: frontal, temporal, 1. Location: frontal, temporal, occipital, neck etc.occipital, neck etc.

2. Family Hx of HA’s2. Family Hx of HA’s3. 13. 1stst started having HA’s: ‘age’ started having HA’s: ‘age’4. Time of onset; am vs pm4. Time of onset; am vs pm5. Frequency “How often” “Change in 5. Frequency “How often” “Change in

freq”freq”6. Intensity or pain level; 6. Intensity or pain level;

scale(??)scale(??)Better ask “Can you still work?”Better ask “Can you still work?”

Headache Hx:Headache Hx:

7. Character type: dull, sharp, 7. Character type: dull, sharp, burning etc.burning etc.

8. Duration “how long to they 8. Duration “how long to they last”last”

9. Cause or Assoc: i.e. eating, 9. Cause or Assoc: i.e. eating, reading, work, stress, CRT’sreading, work, stress, CRT’s

10. Description10. Description

11. Treatments and do the Txs 11. Treatments and do the Txs work?work?

Character type :Character type :

Visual and Past Ocular HxVisual and Past Ocular Hx Ask aboutAsk about: Past Ocular Health: Past Ocular Health

– The Last Eye Exam (LEE) The Last Eye Exam (LEE) How many years?How many years?

– The Dr.’s name and locationThe Dr.’s name and location– The last time their eyes were The last time their eyes were dilated (DFE)dilated (DFE)Last DFE _#_ yearsLast DFE _#_ years

– Age of present Rx and Age of present Rx and age 1age 1stst Rx worn Rx worn

Visual and Past Ocular HxVisual and Past Ocular Hx Ask aboutAsk about: Past Ocular : Past Ocular HealthHealth– Contact Lens HxContact Lens Hx

usage, type, CL wearing time and usage, type, CL wearing time and carecare

– Hx of trauma or infection, Hx of trauma or infection, any treatments and any sequelaeany treatments and any sequelae

– Visual Training (VT) or Visual Training (VT) or patchingpatching

What is a sequelae?What is a sequelae?

By Defn: A sequela is any lesion By Defn: A sequela is any lesion or affection following or or affection following or caused by an attack of diseasecaused by an attack of disease

OUR use : OUR use : Any residual signs or Any residual signs or symptoms of a past disease, symptoms of a past disease, surgery, treatment or trauma. surgery, treatment or trauma.

What is a sequelae?What is a sequelae?

Example: Patient reports being hit with Example: Patient reports being hit with a baseball and “breaking his cheek” a baseball and “breaking his cheek” years ago, he now reports an increase years ago, he now reports an increase in sinus headaches (HA) on that side.in sinus headaches (HA) on that side.– sinus HAs are now a sequelaesinus HAs are now a sequelae

Example: Patient reports seeing Example: Patient reports seeing double when he looks up and to the double when he looks up and to the right ever sense he fell out of a tree right ever sense he fell out of a tree as a child.as a child.– Diplopia is his sequelae Diplopia is his sequelae

Patients Medical HxPatients Medical Hx

Ask:Ask: Last Medical Exam (LME __ Last Medical Exam (LME __ yrs)yrs)– If more than a few years (2-3) ask If more than a few years (2-3) ask further questions esp. femalesfurther questions esp. females

Females usually yearlyFemales usually yearlyMales last visit 10+ years common.Males last visit 10+ years common.

NOTE: If on a Rx medication the LME must NOTE: If on a Rx medication the LME must be within 1 year!be within 1 year!

MD’s name and locationMD’s name and location


Ask aboutAsk about the patient’s General the patient’s General Health: “Constitutional” SystemHealth: “Constitutional” System– How they feel? How they feel? – Fever? Fever? – Fatigue? Fatigue? – Recent weight loss? Recent weight loss?

Last ‘Blood Pressure’ and date, Last ‘Blood Pressure’ and date, Cholesterol level if known?Cholesterol level if known?


Ask ifAsk if “Under care or Observation “Under care or Observation of a MD or clinic”of a MD or clinic”

– NOTE: Care could be as simple as BP NOTE: Care could be as simple as BP checks every 6 mos. Checking a skin checks every 6 mos. Checking a skin freckle once yearly.freckle once yearly.

– IF USING Rx Medications they IF USING Rx Medications they MUST BE MUST BE SEEN YEARLY!SEEN YEARLY!

That would be UNDER CARE.That would be UNDER CARE.

Patients Medical HxPatients Medical Hx If femaleIf female, , ask if pregnant or ask if pregnant or possibilitypossibility? – Teens to Fifty? – Teens to Fifty

Ask:Ask: about any traumas or surgery? about any traumas or surgery? – Any sequelae? Any sequelae?

Especially Head TraumasEspecially Head Traumas

Note: Note: DO NOT ask about “Traumas”DO NOT ask about “Traumas”Ask about; “being Ask about; “being hithit in the head or in the head or eye”eye”

Two Most Important Questions in Two Most Important Questions in the PMHxthe PMHx

1) Medications1) Medications

Ask: “Are you taking any medication Ask: “Are you taking any medication either prescription or non-either prescription or non-prescription “Over the Counter” prescription “Over the Counter” (OTC) ?”(OTC) ?”

Ask: “Are you using any drops?”Ask: “Are you using any drops?” Patients often do not think of drops as Patients often do not think of drops as

medicationsmedications


1) Medications1) Medications

IF yes then follow up with these IF yes then follow up with these ::

1. Ask what medication, dose, reason, 1. Ask what medication, dose, reason, length of time.length of time.

2. Then ask about compliance: “Are 2. Then ask about compliance: “Are you good about taking it as you have you good about taking it as you have been instructed?”been instructed?”


2) Allergies 2) Allergies Next ask “Do you have any allergies Next ask “Do you have any allergies

to medications?” (KMA) and to medications?” (KMA) and

““Do you have any other allergies: Do you have any other allergies: dust, pollen, food, bees, etc.” dust, pollen, food, bees, etc.” (KEA)(KEA)

If YES list: What to, when, the If YES list: What to, when, the type of reaction (Rxn) and type of reaction (Rxn) and treatment (Tx) if needed.treatment (Tx) if needed.

Review of Systems (ROS)Review of Systems (ROS)

The eyes and associated symptoms The eyes and associated symptoms rarely stand alone.rarely stand alone.

Most systems of the body can be Most systems of the body can be influenced by disorders of the eyes influenced by disorders of the eyes and the eyes by disorders of rest of and the eyes by disorders of rest of the body.the body.

Any drug taken for any reason will Any drug taken for any reason will have an effect on the eyes and have an effect on the eyes and vision. Some noticeable, some not.vision. Some noticeable, some not.


E/M coding requirementE/M coding requirement Must ask about 10 of the 14 for Must ask about 10 of the 14 for a comprehensive examination.a comprehensive examination.

– One will be the organ of the CC.One will be the organ of the CC.For us ‘the eye and vision’For us ‘the eye and vision’

– One will be General Health or the One will be General Health or the ‘constitutional’ system‘constitutional’ system


Must ask about three disorders/ Must ask about three disorders/ diseases/symptoms in each diseases/symptoms in each system.system.

Can be asked as a list but need Can be asked as a list but need to stop after each to let to stop after each to let patient respond.patient respond.


Follow the Review of Systems (ROS) Follow the Review of Systems (ROS) choosing those body systems which choosing those body systems which impact the visual system or the impact the visual system or the patient’s CC.patient’s CC.

Example:Example:If about to prescribe an oral If about to prescribe an oral medications ask medications ask

RE: GI symptoms and past disordersRE: GI symptoms and past disorders


Do not ask about the system in Do not ask about the system in general terms, ask or give examples general terms, ask or give examples of disorders which you are looking of disorders which you are looking for:for:

DON’TDON’T: “Do you have any hematological : “Do you have any hematological problems?”problems?”

DODO: “Do you have any problems with : “Do you have any problems with bleeding, bruises, anemia or low bleeding, bruises, anemia or low iron?”iron?”

Recording the ROSRecording the ROS

Record ALL positives and Record ALL positives and pertinent negatives.pertinent negatives.

Record as yes/no or (+) or (-). Record as yes/no or (+) or (-). If positive then need a statement If positive then need a statement for each disorder along with age for each disorder along with age of onset and Tx. Record under of onset and Tx. Record under “Personal or Patient’s Medical “Personal or Patient’s Medical History (PMHx)”.History (PMHx)”.

Recording the ROSRecording the ROS

NOTE: If using (+) and (-) as NOTE: If using (+) and (-) as yes and no, you must circle yes and no, you must circle each. each.

If not then + means “If not then + means “andand” or ” or ““addadd”, and – means “”, and – means “minus minus powerpower” or just a “” or just a “dashdash”.”.

Family eye and Medical Hx: Family eye and Medical Hx: FMHxFMHx

Most often will be combined Most often will be combined with patient’s own ROS:with patient’s own ROS:

Example: “I’m going to ask you Example: “I’m going to ask you about several diseases and about several diseases and disorders, and if disorders, and if you or anyone you or anyone in your familyin your family has any history has any history of them, please tell me.”of them, please tell me.”


Record as yes/no or (+) or (-). If Record as yes/no or (+) or (-). If positive for a family member then positive for a family member then need a statement for each family need a statement for each family member along with age of onset and member along with age of onset and Tx under the FMHx. If positive for Tx under the FMHx. If positive for self then record under the PMHx.self then record under the PMHx.

Record: (+) Dz, who, age, Tx, Record: (+) Dz, who, age, Tx, statusstatus


ExampleExample: (+) DM, mother, age : (+) DM, mother, age 60, Tx “diet”, controlled60, Tx “diet”, controlled

(+) HTN, father, age 40, Tx (+) HTN, father, age 40, Tx “diet and pills”, controlled “diet and pills”, controlled

(+) CA, PG mother, age 70, Tx (+) CA, PG mother, age 70, Tx surgery, deceasedsurgery, deceased

The ROSThe ROS

General HealthGeneral Health “Constitutional” : “Constitutional” : ask about fever, weight ask about fever, weight gain/loss, chronic fatiguegain/loss, chronic fatigue

EyesEyes: In addition to POHx ask : In addition to POHx ask about family ocular history about family ocular history (FOHx) of glaucoma, retinal (FOHx) of glaucoma, retinal detachment, macular degeneration, detachment, macular degeneration, crossed eyes, blindness, early crossed eyes, blindness, early onset cataracts.onset cataracts.

The ROSThe ROS

Ears, nose, throat, and Ears, nose, throat, and mouthmouth: ask about sinus pain : ask about sinus pain or problems, bleeding, or problems, bleeding, hearing loss, sore throats hearing loss, sore throats or hoarseness, difficulty or hoarseness, difficulty swallowing, neck swelling.swallowing, neck swelling.

The ROSThe ROS

CardiovascularCardiovascular: Partly covered by : Partly covered by blood pressure and cholesterol blood pressure and cholesterol levels in PMHx but need also to levels in PMHx but need also to ask about heart problems, ask about heart problems, shortness of breathshortness of breath (SOB), (SOB), swelling of the extremities swelling of the extremities (ankles), (ankles), chest painchest pain, Hx of , Hx of murmurs or irregular beats. murmurs or irregular beats. StrokesStrokes??

The ROSThe ROS

RespiratoryRespiratory: ask about Hx of : ask about Hx of asthma, bronchitis (chronic asthma, bronchitis (chronic cough), SOB, wheezing, chest cough), SOB, wheezing, chest pain.pain.

GastrointestinalGastrointestinal: the big one : the big one is: is: do you have ulcersdo you have ulcers? Others: ? Others: abdominal pain, nausea, abdominal pain, nausea, vomiting, food intolerance.vomiting, food intolerance.

The ROSThe ROS

GenitourinaryGenitourinary: : – Females: are you pregnant or is there a Females: are you pregnant or is there a possibility of pregnancy? possibility of pregnancy?

– Both: do you experience pain or burning Both: do you experience pain or burning on urination, blood, discharge?on urination, blood, discharge?

MusculoskeletalMusculoskeletal: Arthritis, joint : Arthritis, joint pain swelling, muscle weakness, pain swelling, muscle weakness, scoliosis, back pain(esp in AM>1hr), scoliosis, back pain(esp in AM>1hr), gout, hand pains or temperature gout, hand pains or temperature intolerance.intolerance.

MusculoskeletalMusculoskeletal

Eye problems are very common in Eye problems are very common in rheumatologic disorders.rheumatologic disorders.– You can question for rheumatic You can question for rheumatic

disorders easily by asking 3 specific disorders easily by asking 3 specific questions:questions:

1.1. Do you experience pain or stiffness in Do you experience pain or stiffness in your neck, back, muscles or joints?your neck, back, muscles or joints?

2.2. Do you have difficulty dressing Do you have difficulty dressing yourself completely?yourself completely?

3.3. Do you have difficulty walking up and Do you have difficulty walking up and down stairs?down stairs?

MusculoskeletalMusculoskeletal

If they answer NO to all three, If they answer NO to all three, it is not likely that any it is not likely that any rheumatic disorder is present. rheumatic disorder is present. However, some rarer rheumatic However, some rarer rheumatic disorders still would not be disorders still would not be covered by this but most would. covered by this but most would.

If using a computer >2 hrs, If using a computer >2 hrs, ask re: Carpel Tunnel Sx?ask re: Carpel Tunnel Sx?

ROSROS

Integumentary (skin and breast):Integumentary (skin and breast): ask about skin conditions, i.e. ask about skin conditions, i.e. rashes, moles, freckles, warts.rashes, moles, freckles, warts.– If any reported ask about “Changes”If any reported ask about “Changes”

NeurologicalNeurological: Partially covered : Partially covered in 2° Visual Sx (double vision in 2° Visual Sx (double vision and HAs) but also ask about and HAs) but also ask about tumors,tumors, seizures seizures, , dizzinessdizziness, , weakness and fainting.weakness and fainting.

ROSROS

PsychiatricPsychiatric: ask about : ask about depression, panic attacks, depression, panic attacks, anxious tendencies, irregular anxious tendencies, irregular sleep patterns.sleep patterns.

EndocrineEndocrine: ask about diabetes, : ask about diabetes, thyroid, intolerance to thyroid, intolerance to temperature, growth, sudden or temperature, growth, sudden or recent weight loss or gain.recent weight loss or gain.

ROSROS

Hematological/LymphaticHematological/Lymphatic: ask : ask about bruising, anemia (low blood about bruising, anemia (low blood iron), and problems with iron), and problems with bleeding. Any swelling of glands? bleeding. Any swelling of glands? Ask blood type. Ask blood type.

Allergic/ImmunologicAllergic/Immunologic: partly : partly covered under KMA/KEA and sinuses covered under KMA/KEA and sinuses but also, Immunizations?but also, Immunizations?

ROSROS

In addition to the ROS ask In addition to the ROS ask about Cancers.about Cancers.

NOTE: Cancer is NOT a system!NOTE: Cancer is NOT a system! It can occur in any system.It can occur in any system.

– Most important to eye are: Skin Most important to eye are: Skin (melanoma) Lung and breast(melanoma) Lung and breast

ROSROS

NOTENOTE: You must address 10 of the : You must address 10 of the above 14 for a comprehensive above 14 for a comprehensive exam. You may ask more. Some exam. You may ask more. Some of the systems are partly of the systems are partly addressed elsewhere in the addressed elsewhere in the history so they do not need to history so they do not need to be repeated for the personal be repeated for the personal ROS Hx.ROS Hx.

ROSROS

Example:Example: Eye under POHxEye under POHx

General Health under General Health under PMHx,PMHx,

Neurological under HAs Neurological under HAs and and 2° CC.2° CC.

Note the 10 systems requirement only Note the 10 systems requirement only applies to the patient’s health Hx. applies to the patient’s health Hx. It It does not apply to the family does not apply to the family Medical HxMedical Hx..

ROSROS Some systems need only be queried if Some systems need only be queried if the CC warrants.the CC warrants.ExampleExample: Genitourinary. You will ask every : Genitourinary. You will ask every time of all females of child bearing age time of all females of child bearing age about the possibility of pregnancy.about the possibility of pregnancy.

– But other questions: “do you experience But other questions: “do you experience pain or burning on urination, blood, pain or burning on urination, blood, discharge” would only be asked if needed. discharge” would only be asked if needed.

Ex: the patient presented with a red eye of 4+ Ex: the patient presented with a red eye of 4+ week duration or if antibiotic Tx has failed.week duration or if antibiotic Tx has failed.

ROSROS

Keep in mind the history is Keep in mind the history is never completenever complete. .

You may have to return to the You may have to return to the ROS in cases where your exam ROS in cases where your exam findings indicate the need for findings indicate the need for further information of less further information of less commonly asked systems.commonly asked systems.

ROSROS

ExampleExample: The finding of retinal : The finding of retinal hemorrhage would dictate review hemorrhage would dictate review of the Hematological/Lymphatic of the Hematological/Lymphatic system after its detection.system after its detection.

A finding of a subconjunctival A finding of a subconjunctival hemorrhage or if about to give hemorrhage or if about to give an oral medication; an oral medication; Gastrointestinal would need to Gastrointestinal would need to be reviewed.be reviewed.

Social HxSocial Hx: Vocational Requirements : Vocational Requirements & Recreational Needs& Recreational Needs

Ask vocation and be specific!Ask vocation and be specific!i.e. if student, what type? Grade? Grad? Area? i.e. if student, what type? Grade? Grad? Area? Needs are different. Needs are different.

If teacher, what level? Kg? HS?If teacher, what level? Kg? HS?

Ask what is their vision task? TAT? Ask what is their vision task? TAT? LightingLighting

Ask if in OSHA areaAsk if in OSHA area(When appropriate!)(When appropriate!)Ex: Don’t ask a 70 yo secretary.Ex: Don’t ask a 70 yo secretary.But do ask a collage Chem student!But do ask a collage Chem student!


Do they work on a computer Do they work on a computer (CRT), type of task and “Time (CRT), type of task and “Time at Task” (TAT)?at Task” (TAT)?– NOTENOTE: at 2+hr “time at task” : at 2+hr “time at task” patient’s ocular Sx jump in patient’s ocular Sx jump in frequency X2.frequency X2.

Do they read and amt of time?Do they read and amt of time?


Ask if they have hobbies or Ask if they have hobbies or other recreational activities. other recreational activities. – Looking for risks and special Rx Looking for risks and special Rx needsneeds

– High adds, polycarb lenses, etc.High adds, polycarb lenses, etc.


Do they smoke or use tobacco?Do they smoke or use tobacco?– If yes, ask amount: pack per day If yes, ask amount: pack per day for __ yrs.for __ yrs.

– Important in ARMDImportant in ARMD

Do they use alcohol? Estimate Do they use alcohol? Estimate amount.amount.– Especially important in trauma Especially important in trauma cases.cases.


Do they use recreational drugs?Do they use recreational drugs?

Why?Why?

Most 3Most 3rdrd party carriers are party carriers are requiring in the record!requiring in the record!

What IUSO does is have a small check What IUSO does is have a small check box at bottom of intake form.box at bottom of intake form.

SummarySummary

Before you leave the history Before you leave the history we will review what we have we will review what we have recorded for the patient by recorded for the patient by saying:saying:

1. “The reason for your visit 1. “The reason for your visit is….”is….”

(paraphrase the CC) (paraphrase the CC)

SummarySummary

2. Then review the signs and symptoms 2. Then review the signs and symptoms (Sx) of the CC and any positive (+) (Sx) of the CC and any positive (+) answers from the PMH, ROS or the FMH.answers from the PMH, ROS or the FMH.

3. Repeat the medical allergies (KMA) 3. Repeat the medical allergies (KMA) and any Meds even if negative.and any Meds even if negative.

This way we are checking for a mistaken This way we are checking for a mistaken or confused answer that was given or confused answer that was given earlier.earlier.

SummarySummary

4. Then add:4. Then add:

““Is there anything you would Is there anything you would like to add that might have like to add that might have bearing on your eye care bearing on your eye care

today?”today?”

SummarySummary

With so many questions asked With so many questions asked the patient may have forgotten the patient may have forgotten to say something or you may to say something or you may have triggered something the have triggered something the patient thinks may be important patient thinks may be important but was waiting to be asked.but was waiting to be asked.

This allows them that This allows them that opportunity.opportunity.

ReferencesReferences

Bickley, L Bickley, L “Bates’s Guide to “Bates’s Guide to

Physical Examination and Physical Examination and

History Taking”History Taking”, 7, 7thth 8th or 9th 8th or 9th

Ed. 1999, Lippincott, Chap 1 & Ed. 1999, Lippincott, Chap 1 &

2.2.

lecture 3

Health & Medicine

cc hpi

patients cc

time time

history questions richard

comprehensive history

examination patient

series of questions

patients problem