Ординатура / Офтальмология / Английские материалы / Practical Ophthalmology A Manual for the Beginning Ophthalmology Residents 4th edition_Wilson_1996

s^§ Chapter 3: History Taking

Trauma v.- ...

Cases of ocular trauma, especially, can require very detailed reports based on a thorough history (and examination). For medical, medicolegal, and compensation purposes, it is important to obtain the following information:

•The date, time, and place (including the precise address) of the injury

•What happened, in the patient's own words (particularly in the

*' of safety glasses

Past Ocular History

Prior ocular problems can have a bearing on a patient's current status. The existence of any such problems should be discovered so that their possible role in the present illness can be evaluated, and so that thev can be managed if necessary.

To begin with, the patient is usually asked simplv if there have been anv eve problems in the past, but it is often useful for eliciting additional information to ask about the following:

• Use of eyeglasses or contact lenses; the date of the most recent prescription may be recorded here or with the present illness

• Use of ocular medications in the past

•Ocular surgery' (including laser surgery)

•Ocular trauma

• I listorv of amblyopia (lazy eye) or of ocular patching in childhood

If the patient responds positively to any of the above, it might be valuable to ask why, when, how, where, and by whom, as applicable.

2.Recent therapy (within the past 6 weeks, approximately) can affect the patient's present status, because toxic and allergic reactions to topical medications and preservatives sometimes resolve slowly.

All current and prior ocular medications used for the present illness should be recorded, including dosages, frequency, and duration of use. Also ask about the use of any over-the-counter (nonprescription) medications and home remedies.

Patients sometimes do not know the names of their medications. In such cases the physician might at least learn the general classes of medications being used by asking the color of the cap on the container, because containers for eyedrops have caps of different colors to facilitate identification:

•Green: cholinergic (miotic) drugs such as pilocarpine, carbachol, echothiophate iodide (Phospholine Iodide)

•Red: anticholinergic (dilating cycloplegic or mydriatic) drugs such as atropine, homatropine, scopolamine, cyclopentolate, tropicamide, phenylephrine

•Yellow: beta-adrenergic blocking agents such as timolol 0.5%, levobunolol

•Blue: timolol 0.25%, betaxolol (a betaj blocking agent); some other medications have blue tops (eg, tetracycline suspension)

•White: many medications, including certain antibiotics, artificial tears, corticosteroids

•Orange: dorzolamide

General Medical and Surgical History

The patient's present and past general medical history is important for

1.Many ocular diseases are manifestations of, or are associated with, systemic diseases, and

2.The general medical status must be known to perform a proper preoperative evaluation.

•Atopic dermatitis

•Allergic rhinitis, conjunctivitis (hay fever)

•Vernal conjunctivitis

In some instances the presence of these kinds of disorders might already have been elicited in the taking of the present illness, past medical history, or review of systems, in which case it need not be again recorded under "Allergies."

Before injecting dye for fluorescein or other angiography, establish whether the patient has previously been given such an injection and whether any kind of adverse reaction occurred.

Social History

A social history is not always necessary, although it is required by Medicare for certain levels of coding for reimbursement. When relevant, a social history should be taken, including information on such matters as tobacco and alcohol use, drug abuse, sexual history (including sexually transmitted diseases and, perhaps, HIV status), tattoos, body-piercing, environmental factors, and occupation. The questioning should be pursued in a nonjudgmental way, with sensitivity and due respect for privacy. Except as might be required by law, or with the patient's permission, such information should not usually be revealed to third parties.

Family History

The family history of ocular, or nonocular, diseases is important when genetically transmitted disorders are under consideration. The physician might begin by asking a general question such as, "Are there anv eye problems, other than just needing glasses, in your family background?" before asking specifically about corneal disease, glaucoma, cataract, retinal disease, or other heritable ocular conditions.

Knowledge of familial systemic diseases can be helpful in ophthalmic evaluation and diagnosis. Examples include atopy, thyroid disease, diabetes mellitus, certain malignancies, various hereditary syndromes, and many others. Inability of the patient to provide information about the family medical background should not be construed or recorded as a negative family history. Rather, the chart should reflect the fact that the patient's knowledge was incomplete or lacking.

30 Chapter 3: 1 Iistory taking

Examination of family members is occasionally useful when patients present with possibly heritable disorders.

Pitfalls and Pointers

•Avoid taking an insufficiently detailed history. The history need

•A good history may be brief or lengthy, so long as it is thorough relative to the ultimate goal of helping the patient. The ability to take an essentially complete, yet efficient, history is an important aspect of the art of medicine. Nevertheless, the beginning ophthalmology resident whose histories fall short of being ideal should not be dismayed; the skill improves greatly, and almost automatically, with experience.

•When taking a prenatal and gestational history, avoid phrasing your questions in a way that would elicit guilt feelings or imply causal relationship between a child's ocular disorder and anything the mother might have done or not done.

Suggested Resources

Lloyd B-J. History-Taking in the Ophthalmologist's Office [Allied Health Audio Education audiotape]. San Francisco: American Academy of Ophthalmology; 1990.

Trobe JD. The Physician's Guide to Eye Care. San Francisco: American Academy of ( )phthalmologv; 1993.

Test Targets

A variety of test targets are used in visual acuity testing (Figure 4.1). Each individual letter, number, or picture on a testing chart is referred to as an optotype. Charts with such optotypes have achieved almost universal acceptance in the United States. Some optotypes are more diificult to recognize than others. For example, B (a relatively complex letterform) is the hardest for patients to recognize and can easily be interpreted as an E or the number 8. The letters C, D, and O are often confused because their shapes are so similar. The easiest letter to recognize is L, which can be mistaken for few letters other than the letter I. This means that the examiner can consider a patient's misinterpreting a B during visual acuity testing to be less significant than missing an L.

Most letter and number charts available require some degree of literacy and some verbalization skills. The tumbling E and Landolt C tests can be done on a matching basis, but both involve some degree of laterality and therefore test psychophysical components other than vision. Picture charts are nonthreatening for young children but may result in overestimation of visual acuity because, as with certain letters, the optotypes are not equally recognizable; children easily learn the limited number of optotypes used, which can result in inaccurate acuity measurements due to educated guessing. Picture charts are excellent for fixation targets, however. A test involving a chart and matching cards employing the four letters H, O, T, and V has been introduced

B

Figure 4.1 Charts for distance visual acuity testing. (A) Snellen lette

(B) Alien picture chart.

ple, if three letters were missed on the 20/40 line, the acuity can be expressed 20/40~3. If the patient missed three letters on that same line but was only 15 feet away from the chart, the expression is modified to 15/40"1. If the patient reads several letters on the next smallest line, the examiner may modify the superscript notation with a plus sign instead of a minus sign and denote the number of letters read correctly.

Standard Abbreviations

Testing Procedures

section presents general background and specific steps for performing distance, pinhole, and near visual acuity testing and for measuring near point of accommodation and near point of convergence.

Distance Acuity Test

On an initial visit, a patient should be tested both with and without corrective lenses. When recording visual acuity test results in ilie patient's record, the abbreviation cc indicates that corrective lenses were worn for the test. When vision is measured without the use of