Transcript Follow the Signs:

Follow the Signs:
Advanced thinking in a patient encounter
Amanda Waggoner, COMT
Objectives
• -Become more efficient technicians
• -Identify information and testing needed to BEST help the patient and
doctor
• -Streamline exam time
STOP
• Remember to stop before each patient and take a breath to prepare
for a new encounter.
• Don’t assume because a patient is scheduled for a specific type of
exam that is why they are here.
• Take a moment to review their past history to see if any testing was
requested for the next exam and to familiarize yourself with their
history.
• Be Proactive-If the patient has a specific problem and regular testing
is indicated and overdue take action (test same day, alert Physician,
schedule for another date).
LISTEN
• Listen to what the patient is complaining of and clearly state this in
the record.
• Try to stay out of a “rut” of common complaints (Blurred vision, red
eye, etc.) Use the patients words when documenting complaint.
• Realize some patients will not want to complain, while others will tell
you everything. Try to guide the patient to focus on what is their
main reason for being there.
• Repeat their complaint as you are entering it to make sure you are
“hearing” them correctly.
Chief Complaint
• The chief complaint is your guide.
• Remember to ask questions about complaints, a general “floaters”
could be a number of problems. As technicians WE can make the
Physicians job easier when learning to recognize signs that lead us to
proactively streamline an exam and save time.
Floaters
Posterior Vitreous Syneresis
Light or dark colored “spots” in vision. Move with gaze
and if patient tries to focus on them.
More noticeable in Bright light. How many? Changing
Shape? Any flashes of light?
Ophthalmic migraine
Light pattern, described as (lightning shaped, heat wave,
circular pattern). Usually only lasting 10 min-30min, may
or may not be followed by a headache. May start
peripherally and move central. Symptoms can be OU.
Loss of Vision
Blurred Vision
Blurriness, Glare. Gradual or sudden?
With glasses or without? Near vision or distance?
Associated pain or redness with onset?
“Gone” vision
Blanked out or darkened out area’s. Sudden or gradual?
Distortion in vision? Health history can be a big clue.
Recent history of “bumping” into things on a side,
or trouble judging space when parking?
Red Eye
Subconjunctival hemorrhage
Iritis
• Blood red, completely covering
an area. May have started small
but grown in size. Other people
may have noticed first. No
change in vision. No pain or only
slight irritation.
• Engorged red veins. Patients
may also complain of decreased
vision, light sensitivity, and
aching.
Pain
Irritation/ Foreign body
Achiness/Soreness
• Duration? What helps relieve
symptoms? Injury or Chemical
exposure? CL wearer? Tearing
or discharge?
• Duration? Location? Change in
vision? Light sensitivity?
Associated headache or nausea?
Double Vision
• Monocular-not a muscle issue.
• Any distortion? Think retina.
• Double not “real” images only
with lights? Think media
opacity.
• Vision described as elongated or
skewed? Think refractive error.
• Binocular-goes away with one
eye closed.
• All the time? If not, when do
symptoms start? Near, Distance
or both?
• Sudden onset or worsening over
time?
• Any associated lid droop or pupil
changes noted?
LOOK
• Observe the patient while taking histories.
-Redness and swelling
-crusting or discharge on lids
-proptosis of one or both eyes
-Eyelid closing or guarding of an eye
-abnormal head positioning
-facial or eyelid droop
Make note on chart
Exam-Visual Acuity
Testing strategies-Snellen/Allen/Tumbling E’s/numbers
use what is easiest for the patient to understand
-Pinhole-Use when BCVA is lower than expected
Special Cases
Language barriers/ Nystagmus/ “surprise loss of vision”
EOM and Cover Testing
• Test with glasses so patient can fixate at distance/near easily. Position
correctly so patient is using the right part of glasses.
• Check Corneal reflexes-I use a pen light while doing EOM’s so I can
“double check”
• Never rely on past exam findings-Did the last Tech miss it? Has the
patient developed a palsy since last exam? ONLY RECORD IN A CHART
WHAT YOU HAVE CHECKED YOURSELF!
• ALWAYS have the doctor check patient before dilation with new onset
or change in diplopia that is constant or frequent.
EOM and Cover Testing
• Our job as technicians is to recognize anything “abnormal. Do not
worry if you can’t specify the exact prism diopter needed. The
physicians will have more trust in you if you notice a problem and
have them check, than if you ignore it because you are nervous about
getting the “right” answer.
• If everything is ortho on exam but you pick up Prism in the glasses,
recheck without glasses. Patients do not always know to tell us
because with glasses VA is fine. If no diplopia with current, Great! We
still need notation of why it is needed.
EOM and Cover Testing
• EOM-What are we checking?
• Use a Square or Star shape.
• Make sure you are extending
far enough in each direction
for the patient to reach endgaze.
- If the patient has difficulty following your fixation device you can
verbally ask them to look in each direction.
- Do not be afraid to lift a lid if needed, or check for corneal reflex in
different positions.
EOM and Cover Testing
• We are not Magicians…avoid the magic wand!
• Determine Tropia vs. Phoria
Cover/Uncover to determine Tropia
Alternate Cover test to determine Phoria
-Check both ways!
Confrontation Visual Fields
• We are not performing a full visual field! This is a screening
evaluation to pick up gross loss.
• Why is it important? Retinal vascular problems, Optic Nerve
dysfunction, Stroke, Brain Tumor…Big stuff!
• We are testing against our own assumed normal visual field, cover
your opposite eye so the target is seen simultaneously by the
patient and you.
• If VA is poor use a light, a bright colored medicine cap or hand
motion can be used for a target.
Visual Pathway
When doing Confrontation visual fields,
know your Visual Pathway. This is a “map” to
where any dysfunction is stemming from.
Prechiasmal-Monocular defects
Chiasmal- Heteronymous defects-the chiasm
is the only place nasal fibers from both eyes
can be affected.
Postchiasmal-Homonymous defects-The
more congruent (same) the defects are, the
more posterior in the brain the lesion is
located.
Pupils
• Always check before dilation! If unsure get a double check.
• Do not assume the last technician was correct. If the patient has an
Optic Nerve condition or poor vision suspect possible APD and always
check.
• If no new complaints and 20/20 VA, APD is unlikely.
• Check for subjective APD-ask the patient which eye is the light
brighter in, this can be found even in early cases of Optic Neuropathy
where an APD may not yet be completely visible.
Pupils
• Anisocoria? <1 mm difference in pupils is considered anatomically
normal.
• Any Trauma to either eye (past or new), Surgery on one or both
eyes?, History of inflammation (iritis)?
• Is one eye dilated? Has the patient been exposed to any chemicals,
are they using a redness reliever frequently, have they used a motion
sickness patch, is it associated with a migraine?
• Is one eye miotic? Any associated symptoms of lid droop or eye turn?
Does the pupil react to convergence (assess while patient focuses on
small print).
Refractometry
• Where do I start? Lensometry/ Last MR on
record/Autorefraction/Retinoscopy
• Do not forget to check for cylinder, if no previous Rx available or
autorefractor start with option of .50 at both main and oblique.
• Balance changes in cyl and sphere.
• Use your tools: Fogging/ Red-Green
• Does complaint “match” RX? Latent Hyperopes, Cataract changes,
Diabetic changes?
Refractometry
• Handling the patient
-”I hate this test, I can never decide”
-”you are not giving me enough time”
-” I like choice 2, from 5 min ago best”
-”shouldn’t the Doctor be doing this?”
Refractometry
• ADD power, Does it make sense??? Preferred position of material.
Special Circumstances
• Low vision (eccentric fixation, rolling spheres, aphakia, high ADD).
• Trial frame MR (Tremors, head positioning or physical disability).
• Illiterate or Developmentally disabled patients.
• Vertex and do quick OR with current glasses
• Be Flexible and creative.
Slit Lamp
• We are not “just” checking pressure.
• Always do a quick sweep of each eye to determine any abnormalities.
• Check with white light-lids and lash margins/ Cornea/ Anterior
Chamber depth/ iris
• Check under blue filter with fluorescein- Tear film break up time and
any staining.
• Perform Applanation tonometry
• RECHECK cornea! If you catch a lash or abrade the cornea you want
to know before the doctor finds it!!!!
Lid/Lash Abnormalities
Cornea
Anterior Chamber
Iris
Fluoroscein staining
Tonometry
• Always check your equipment. Is the tonometer prism clean? Are the
marks aligned at 180? Make sure when swinging into position,
everything “clicks” into setting.
• Remind the patient to keep their mouth shut (this is really the only
time we can get away with this), breathe normally, teeth together,
and BOTH eyes open.
• If you need to hold a lid put minimal pressure against the globe, try to
use the brow bone instead.
• CLEAN YOUR TONOTIP after use, and swing tonometer back to the
“resting” position.
Tonometry
• If a value is outside of normal and you are unsure of reading, recheck.
• This is where Histories can be a help. Is the patient on Glaucoma
Therapy and are they compliant? Are they using any steroids (ocular
or systemic), Do they have Thyroid problems (check in straight gaze
and upgaze), are they postsurgical?
• If reading is high and has always been high normal-are their angles
open? Has Pachymetry ever been done?
• Do not proceed with IOP if possible Shingles/HSK. If there are any
corneal complaints check eye before proceeding with drops and IOP
reading. It is OK to defer and ask before “touching” an eye.
Dilation
• Check for drop protocol when working in unfamiliar clinics.
• ALWAYS check your labels before instilling drops.
• If Latent Hyperopia is suspected or possible use a Cycloplegic drop.
• Explain to the patient vision will be affected and that they will need
sunglasses.
• If the patient complains of previous “allergy” get specifics on reaction
and ask the physician how to proceed.
When do I not use drops?
No drops before Physician OK
DO NOT DILATE
• Suspected HSK/Shingles
• Foreign body or trauma injuries
where Penetration of anterior
chamber is possible.
• Post surgical for Ruptured globe,
large corneal or scleral incision
repair, refractive surgery by
protocol.
• If prism needs to be assessed.
• If the patient presents with a
possible Neurological problem
and there is a possible APD.
• If there are any iris abnormalities
that need to be measured or
seen by physician.
• If narrow angle suspected.
Testing
• Brightness Acuity Testing
-glare complaints
-History of Cataract or possible PC
haze.
Check if visual acuity is better
than 20/50 on any Cataract eval.
Insurance requires for
qualification to proceed with
surgery.
• Pachymetry
-High normal-high IOP
-Glaucoma evaluations
-Peripheral cornea if surgeon
planning a manual LRI
-Corneal Dystrophies
Be proactive, if not in chart go
ahead and check with Glaucoma/
Ocular Hypertension.
Testing
• Amsler
• Color Testing
-distortion complaints
-Flashes/Floaters
-monocular diplopia
-screening with cataract
evaluations
-High Risk Medication patients
-Kids
-Multiple Sclerosis patients
-High Risk Medication patients
-Optic Nerve/ Neuro
-Traffic Lights for DMV
Testing
• Hertel / exophthalmometer
• Corneal Topography
-Thyroid Eye Disease
-Traumatic injuries that may
involve orbit.
-Scleral show or Proptotic
appearing eyes.
-Pre or Post LASIK/RK patients
-Post PKP patients
-irregular astigmatism with
decreased best corrected vision
-History of Kerataconus
Testing
• OCT-Macula
• OCT-Optic Nerve
-Post Surgical with decreased
vision
-High risk Medication patients
-Change in Amsler grid
-loss of central vision or
complaints of
micropsia/macropsia
-Glaucoma
-Ocular Hypertension
-Optic Neuritis/ Ischemia
-Change in color discrepancy
between eyes
Conclusion
• Think while doing the exam- What could this be? What can I do to
rule in or out any possibilities? Is there a finding I am uncomfortable
making a firm decision on?
• Do not be afraid to ask for help.
• Be proactive. Is there information you can give the patient to
facilitate their understanding of a condition?
• Review the charts after doctor has seen patient to see what the
outcome was, use this as a learning tool.
• Have PASSION for your job, always keep learning!