Transcript Document

Clinical
techniques and
refraction
Case History
Clinical thought
Case
history
(1)
Tentative
diagnosis
(2)
Specific
tests
Analysis of
information
(5)
Optometrical
investigation
(3)-(4)
Definitive
diagnosis
(6)
Treament
plan
(7)-(8)-(9)
Objective of the clinical history
Objective
Extract information from the patient that will be useful in
determining the specific tests that should be performed during
the visual investigation in order to, after their interpretation and
analysis, arrive at a definitive diagnosis and a treatment plan.
Reflections before beginning
Important points
• The patient’s case history begins in the first few
minutes of the visit but continues throughout the
duration of the clinical examination
• When creating a case history, keep in mind the
prevalence and incidence of visual conditions
and ocular illnesses as well as their relation to
age.
• It is important to establish an appropriate
professional-patient relationship.
Reflection before beginning
Example of the question in the case history
Most frequent errors
• Premature or hasty conclusion: a conclusion
before obtaining all of the information necessary
and stopping the investigation.
• Pseudodiagnosis or inadequate synthesis: all of
the information is extracted but at the end there is
no diagnosis.
• Lack of trust on the patient’s behalf
• Letting oneself be guided by intuition, etc
Common errors
Sections of the case history
Sections of the case history
• Personal information
• Main reason for the consultation (MC)
• Personal history (PH)
– Ocular and general health history
• Family history (FH)
– Ocular and general health history
• Visual needs at work and other activities
Personal information
Personal information
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First and last names
Date of the appointment
Date of birth and current age
Complete address and telephone number(s)
Sex/Race
Profession
Sent/recommended by
Observations
Main reason for the consultation
Reason for the consultation
Reason for the consultation (MC): the objective is
to determine the possible etiologies of the visual
problem the person shows, depending on the
symptoms that the person manifests.
Reasons for the consultation
Reasons for the consultation
• Reasons for the consultation (MC):
– Main reason for the consultation
• Open question
“What is the reason for your visit?”, “Why have you
come to see us?”, “What’s wrong?”…
• Write it down in the patient’s words
• Continue with more questions in order to get to the
main and any secondary symptoms: when, how,
where, from distances, from near…
Reasons for the consultation
Examples of questions to center on the reasons for
the consultation
Most frequent symptoms
Most frequent symptoms
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Blurry vision
Visual fatigue
External ocular discomfort
Headaches
Loss of vision
Other visual discomfort
Most frequent symtoms
• Blurry vision (functional
causes):
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Ametropia/Presbyopia
Amblyopia
Accomodative dysfunction
Binocular dysfunction
Simulation/ocular hysteria
• Blurry vision (pathological
causes):
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Corneal/crystalline alteration
Inflammation
Vitreous opacities
Macular problems
Problems with the optic
nerve
Most frequent symptoms
• Visual fatigue:
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Ametropia/Presbyopia
Binocular dysfunction
Accomodative dysfunction
Anisometropia/aniseikonia
Inadequate optical correction
Inadequate environment
Most frequent symptoms
• Double vision (diplopia):
– Ametropia
– Binocular dysfunction
– Monocular diplopia
Most frequent symptoms
• Loss of vision (of visual
acuity):
– Migraine
– Optic neuritis
– Occlusion of retinal vein or
artery
– Temporary arthritis
– Papilloedema
• Loss of vision (of field of
vision):
– Retinal lesions/loosening
– Anomalies of the visual
pathway
Most frequent symptoms
• Discomfort related to the anterior segment of
the eye
– Excessive tearing
– Reddening/Itchy eyes
– Sensation of foreign body
Most frequent symptoms
• Headaches:
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Ametropia/Presbyopia
Binocular dysfunction
Accomodative dysfunction
Vascular: migraine, tensional, etc.
Inflammatory, tumoral, etc.
Most frequent symptoms
• Headaches:
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Ametropia/Presbyopia
Binocular dysfunction
Accomodative dysfunction
Vascular: migraine, tensional, etc.
Inflammatory, tumoral, etc.
Personal history
Personal history
• Visual and ocular personal history
– If he/she wears glasses and/or CL
• How long have you worn glasses? How long have you
had this prescription? When was your last check-up?
When or for what do you wear the glasses? Do they
work well for you?
• Test the graduation to the frontal focometer and the
centration distance,  effects, material, color, design, etc.
– If he/she does not wear glasses
• Have you ever worn glasses? When was your last eye
exam?
Personal history
Personal history
• Visual and ocular personal history
– Ocular traumas
– Is the person using any drops or creams for the
eyes? Has he/she ever used any?
– Past or present ocular illnesses
– Ocular operations or operations in surrounding
areas
Personal history
• Personal history of general health
– General health
• Current state of health? Any health problems like
diabetes, hypertensión, etc.?
– Medication:
• Is he/she taking any medication? Why? For what?
When? Since when? How much?
• Has he/she taken any medication recently?
• Are there any known allergies?
Family history
• Family history (FH)
– Ocular history and general health
• Interrogation directed at conditions with a possible
hereditary factor and that can affect the vision:
glaucoma, diabetes, retinal detachment, severe loss
of vision, ocular or arterial hypertension, etc.
Visual needs
• Visual needs
– What do you do? Distance, lighting, size, etc.?
– Any hobbies that require visual exertion?: reading,
painting, sewing, music, etc.
Relevant observations
• Observations: any relevant TRAZO from external
factors
Case file
• Personal information
• MC, PH, FH
• Refractive section:
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PD
AV
Retinoscopy and Subjective
Others
• Visual efficiency:
– Binocularity
– Accomodation
– Ocular motility
Case file
• Personal information
• MC, PH, FH
• Refractive section:
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PD
AV
Retinoscopy and Subjective
Others
• Visual efficiency:
– Binocularity
– Accomodation
– Ocular motility
• Treatment plan
• Future visits
• Ocular health:
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Anterior segment
Eye exam
Visual field
Pupillary function
Intraocular pressure (IOP)
• Ex. complementary:
– Color vision
• Diagnosis
Associated practice
• Practice 1: Case history between fellow
students in the group
• Practice 2: Case history of external patients
Work outside the classroom
• Creation of a list of questions to ask in
distinct hypotheses:
– 15-year-old that attends a revision due to loss of
far vision
– 38-year-old adult that attends a revision due to
loss of near vision
– 70-year-old elderly patient that attends a revision
for loss of vision
Bibliography