Ординатура / Офтальмология / Английские материалы / Practical Ophthalmology A Manual for the Beginning Ophthalmology Residents 4th edition_Wilson_1996
.pdfptcr 2: Overview of the Ophthalmic Evaluation
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•Refractor. This device (also called a Phoroptor) stores a range of trial lenses and is used to perform retinoscopy and refraction (see Chapter 5).
•Trial frame and loose trial lenses. This equipment is used to perform retinoscopy and refraction and to double-check refractive findings (see Chapter 5).
•Penlight or Finnoff transilluminator (muscle light). These instru-
ments are used to check pupillary light reflexes and the corneal light reflex. Auxiliary uses include illumination tor the external
• examination and transillumination of the globe (see Chapters 6, 7, and 9).
•Direct ophthalmoscope. This handheld instrument is used for posterior segment examinations and also to assess the red reflex (see Chapter 13).
•Indirect ophthalmoscope. This device, worn on the head, is used for the posterior segment examination in conjunction with auxiliary handheld diagnostic condensing lenses (see Chapter 13).
•Streak retinoscope. This handheld instrument is used to perform retinoscopy, an objective measurement of a patient's refractive state (see Chapter 5).
•Keratometer. This device measures corneal curvature and is t\pically used to assist in fitting contact lenses and to diagnose disorders such as keratoconus.
•Prisms. These optical devices, available individually or held together in a prism bar, are used in the motility examination (see Chapter 6).
•Sensory testing equipment. The Worth four-dot testing equip-
ment consists of a |
flashlight that illuminates four colored dots, |
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and red-green eyeglasses for the patient to wear. It is used during |
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the motility examination to test binocular vision. The most com- |
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mon test of stereopsis is the litmus test, consisting of a stereo- |
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scopic test booklet and a pair of polarized spectacles. It is also |
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used as a part of the motility examination (see Chapter 6). |
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• Color vision testing equipment. Standardized books of colored |
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plates, such as the Ishihara pseudoisochromatic color tests, are used |
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when congenital or acquired color vision defects are suspected (see |
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Chapter 4). |
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Medical Record Keeping |
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Physician Demeanor and Approach to the Patient
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When performing the ophthalmic evaluation, the ophthalmologist's |
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approach to the patient should be characterized by compassion and |
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professionalism. Listen to patients' concerns carefully and with undi- |
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vided attention. Patients' descriptions of ocular problems, in their own |
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words, are of vital importance in ocular history taking. After complet- |
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ing the ophthalmic evaluation and counseling the patient, it is advisable |
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to ask if the patient has any additional questions or concerns and to |
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address them at that time. As in any medical setting, it is important to |
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maintain the confidentiality of all patient information and interactions. |
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Certain situations can create barriers to effective patient-physician |
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communication. When the patient and the ophthalmologist do not |
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speak the same language, bilingual family members or staff can often |
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bridge the communication gap by translating for the patient and |
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' physician. If a translator is needed to obtain informed consent for a |
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procedure, consult the hospital administration regarding the institu- |
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tion's policies. |
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In some situations, the mental status of the patient limits the extent |
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of first-person history taking. In these cases, the family members, |
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guardians, or attendants of the patient can usually provide additional |
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important information. Some patients have a deep-seated fear of the |
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health care environment that inhibits their ability to communicate, |
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while other patients have an unspoken fear of blindness that can cause |
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them to minimize or exaggerate ocular complaints. By creating an |
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atmosphere of trust, respect, and openness, the ophthalmologist can |
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encourage the patient to communicate freely, and effective patient- |
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physician communication can be achieved. |
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Pediatric patients warrant special consideration. The parent or care- |
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taker will be the primary source of information for preverbal children. |
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Older children should be involved as much as possible in history taking |
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and in discussions of the findings and treatment plans, depending on |
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both the child's age and ability to communicate and comprehend. |
Medical Record Keeping
Concise, legible, and complete documentation of the ophthalmic evaluation allows the ophthalmologist and other caregivers to refer to the data in the future and is thus of tremendous importance to patient care
f and continuity of care. Although some abbreviations are widely used,
T|i8 - Chapter 2: Overview of the Ophthalmic Evaluation
ophthalmologic medical records should be written using terminology that will be understandable to all health care providers who will access the medical records. An excessive use of jargon should be avoided. As a medicolegal document, the medical record must present complete and sufficiently detailed findings and treatment recommendations.
Communication with referring physicians and other health care providers, whether written or verbal, is crucial in providing the patient with continuity and coordination of care. Such communication should be clear, timely, and complete.
Some ocular conditions occur as manifestations of systemic diseases that constitute a threat to public health, such as gonococcal conjunctivitis and HlV-related ocular infections. Some diseases, by statutory guidelines, must be reported to the state health department. Reporting guidelines vary from state to state; the ophthalmologist should contact the state health department for appropriate guidelines.
Pitfalls and Pointers
•New residents in ophthalmology might at first feel overwhelmed by unfamiliar diagnostic techniques, equipment, and nomenclature. This reaction is normal. With hard work, perseverance, and diligent studv, the unfamiliar seems like second nature in a relatively short time.
•As you strive to master new ophthalmologic techniques and skills, don't lose sight of the fact that a patient sits behind the retractor.
Suggested Resources
Comprehensive Adult Eye Evaluation [Preferred Practice Pattern]. San Francisco: American Academy of Ophthalmology; 1992.
Comprehensive Pediatric Eye Evaluation [Preferred Practice Pattern], San Francisco: American Academy of Ophthalmology; 1992.
Keltner JL, Wand A'l, Van Newkirk AIR. Techniques for the Basic-
Ocular Examination [videotape]. San Francisco: American
Academv of Ophthalmology; 1989.
.m.
History Taking
although similar to the general medical history that you learned in medical school, the ophthalmic history naturally
emphasizes symptoms of ocular disease, present and past ocular
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problems, and ocular medications. The history is intended to elicit any information that might be useful in evaluating and managing the patient; it may be as brief, or extensive, as required by the patient's particular problems. This chapter provides an overview of the ophthalmic history, its goals, recording methods, and components.
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20 Chapter 3: History Iaking
Goals of the History
The history should allow for the recording of a variety of important information that could affect the patient's diagnosis and treatment. The five most important objectives are listed below:
1.Identifying the patient: If not already done, demographic information about the patient should be recorded (eg, name, address, date of birth, sex, race, and medical record number).
2.Identifying other practitioners who have cared for the patient: Such individuals might need to be
a.Contacted for additional information;
b.Given information about the patient, especially if the patient was referred by another practitioner, in which case a written
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report is required. Reports also are often needed following |
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referrals from attorneys, insurance companies, or governmental |
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c.Involved later in the care of the patient.
3.Obtaining a diagnosis: The likely diagnosis, or a least a reasonable differential diagnosis, can often be suspected merely on the basis of
agood history. This, in turn, allows for the planning and tailoring of a more useful and efficient examination.
4.Selecting therapy: Knowledge of treatments that have already been tried, and whether or not (and in what ways) they were helpful, is invaluable in planning therapy for the future. An awkward situation can arise if a physician recommends therapy, only to learn that the same therapy has already been tried and has failed. Insufficient knowledge of the results of prior therapeutic efforts can also lead to misdiagnosis.
Where therapy is concerned, it is important also to tryto ascertain what the patient wants and expects from the physician. This can be done directly by questioning the patient or, in many cases, indirectly by listening attentively to, and interpreting, what the patient says. Some patients require definitive therapy, whereas others need only explanation and reassurance, documentation of a problem, or periodic observation.
5.Socioeconomic and medicolegal considerations: Insurance payments, workers compensations, disability payments, and the like (on the patient's behalf), as well as legal proceedings, often depend on detailed, accurate reports (or even testimony) from the physician. Such reports can be inadequate, and sometimes even humiliating
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Methods of Recording the History |
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for the physician, if a thorough history has not been obtained. In addition, a well-taken history can save time and expense by obviating needless tests and examination procedures. Such efficiency and cost containment is of ever-increasing importance in the current environment of evolving managed care. Also, the components and thoroughness of the history are considered, and may be audited, by Medicare to determine the appropriateness of coding and charges for services.
Methods of Recording the History
,„ The precise method of recording the history is unimportant unless a
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practice or institution has specific requirements. The history mav be |
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handwritten on blank paper or on a preprinted form, dictated for later |
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transcription, or entered into a computerized database. Figure 3.1 dis- |
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plays one type of preprinted history chart that some physicians find |
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useful. |
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Patient Data |
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Name |
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Address |
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Telephone (work) |
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(home) |
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Date of Birth ___ / / |
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Sex DM |
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Race |
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Referred bv |
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Referrer's address |
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Medical Record Number |
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Insurance carrier |
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Patient History |
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1. Chief complaint |
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Present illness |
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Past ocular history |
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4. Ocular medications |
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5. General medical/surgical history |
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6. Systemic medications |
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Allergies |
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Social history . |
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Family history |
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Figure 3.1 One type of preprinted history chart.
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Chapter 3: History Taking
Components of the History
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As described below, the components of the ophthalmic history are essentially the same as the components of any general medical history, except that ophthalmic aspects are, of course, emphasized. The nine components of the history are
1. Chief complaint
• 2. Present illness |
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3.Past ocular history
4.Ocular medications
5.General medical and surgical history
6.Systemic medications
7.Allergies
8. Social history
9. Family history |
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Chief Complaint
The patient's main complaint(s) should be recorded in the patient's own words or in a nontechnical paraphrasing of the patient's words. It is not advisable in this early phase of the history for the ophthalmologist to draw hasty conclusions by employing medical terms that suggest premature diagnoses. For example, chief complaints should be listed as redness, burning, and mattering or light flashes instead of conjunctivitis or photopsias. The patient's own words are important for knowing, and being able to document, the patient's point of view, as distinct from that of the physician. The physician's impression is appropriate only later, after a proper history has been taken and a suitably thorough examination has been performed.
Of course, patients are sometimes troubled by more than one symptom or problem and so may have more than one chief complaint. Even problems that are of lesser importance should be cited along with the chief complaint. Some examples of kinds of questions that can help to elicit the patients main complaints are listed in Table 3.1.
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Components of the History
Table 3.1 Questions for Eliciting the Chief Ophthalmologic Complaint
Consider using one or more of the following questions to determine the patient's chief complaint or complaints.
•What are the main problems that you are having with your eyes?
•What other problems are you having with your eyes?
•Why did you come (or why were you sent) here?
•In what way are you hoping that you might be helped?
•What is it about your eyes that worries or concerns you? (This type of question sometimes reveals entirely unfounded fears, such as blindness or cancer.)
•What is the main problem that you would like me to address?
Present Illness
Evaluation of the patient's present illness consists mainly of an effort to record additional information and details about the chief complaints). The patient's own words may be used here when desired, although the physician's words, including medical terminology and abbreviations, are more often used to represent what the patient said. Information elicited about the present illness allows the ophthalmologist to begin developing a preliminary diagnostic impression.
The following general areas of inquiry are given as suggestions for developing information about the present illness.
•Time and manner of onset: Was it sudden or gradual?
•Severity: Has the problem improved, worsened, or remained the same?
•Influences: What might have precipitated the condition, made it better or worse, or made no difference? Asking about prior therapeutic efforts is especially important, and it is helpful to know when the patient's refractive prescription was last changed.
•Constancy and temporal variations: Has the problem been intermittent or seasonal, or does it worsen at a particular time of day? If so, were there any influences that seemed to precipitate exacerbations or remissions?
•Laterality: Is the problem unilateral or bilateral?
•Clarification: It is sometimes necessary to clarify what the patient means by certain complaints. For example, does mattering of the eye mean sealing of the eyelids by sticky discharge, the mere pres-
Chapter 3: History Taking
ence of strands of mucus at times, or simply the noting of tiny granules on the eyelids (as from dried mucus or the drying and crystallization of eyedrops)? Countless other situations exist in which it is important to clarify just what the patient means, so it is vital to question the patient thoroughly.
• Documentation: Old records, or even old photographs, can be of value in documenting the presence or absence of particular problems in the past (eg, ptosis, abnormal ocular motility, proptosis, facial nerve palsy, anisocoria).
Specific complaints that might be recorded under "Present Illness" are too numerous to list here in their entirety. Nevertheless, one needs to keep in mind certain general categories of complaints, which are listed below together with examples of accompanying specific complaints. :"••".'
Disturbances of vision
•Blurred or decreased central vision (distance, near, or both)
•Decreased peripheral vision
•Altered image size (micropsia, macropsia, metamorphopsia—the last referring to distorted images)
•Diplopia (monocular, binocular, horizontal, vertical, oblique)
•Floaters (moving lines or specks in the field of vision)
•Photopsias (flashes of light)
•Iridescent vision (halos, rainbows)
•Dark adaptation problems
•Dyslexia (medical inability to read with normal understanding)
•Color vision abnormalities
•Blindness (ocular, cortical, perceptual)
•Oscillopsia (apparent movement or shaking of images)
Ocular pain or discomfort
•Foreign-body sensation (a feeling of scratchiness, as though a
particle were present on the surface of the eye) |
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•Ciliary (deep) pain (an aching, often severe, pain within and around the eye, sometimes radiating to the ipsilateral temple, forehead, malar area, and even the occiput, secondary to spasm of the ciliarv muscles)
Components of the History |
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•Photophobia (a less severe form of ciliary pain that is present only upon exposure to light)
•Headache (not attributable to ciliary pain)
•Burning
•Dryness
•Itching; true itching, which compels the patient to rub the eye(s) vigorously (and which usually indicates allergy), must be differen-
tiated from burning, dryness, and foreign-body sensation
•Asthenopia (eyestrain)
Abnormal ocular secretions
•Lacrimation (tearing—welling up of tears on the ocular surface)
•Epiphora (actual spilling of tears over the margin of the evelid onto the face)
•Dryness (also considered discomfort, as listed above)
•Discharge (purulent, mucopurulent, mucoid, watery; the first two kinds of discharge are associated with neutrophils and cause true sealing of the eyelids in the mornings)
Abnormal appearances |
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Ptosis (drooping of the eyelid) |
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Proptosis or exophthalmos (protrusion of the eye or eyes) |
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Enophthalmos (the opposite of proptosis) |
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Blepharitis (sometimes referred to by patients as granulated eyelids) |
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Misalignment of the eyes |
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•Redness, other discolorations, opacities, masses
•Anisocoria (inequality of the pupils)
Other complaints
•"Something my doctor wanted to be checked"
•The need for a second opinion regarding diagnosis, surgery, or other management