Asking the Right Questions Makes All the Difference
Arriving at the correct diagnosis is dependent on complete history taking. A recent article in CNN highlighted this issue. It’s about a Scottish man named Martin Taylor who started having severe respiratory problems. He couldn’t even walk from one room to the next without becoming out of breath and needing to sit down. Doctors couldn’t figure out what was wrong with him and his chest X-ray was deemed normal.
Eventually, a chest physician was consulted. He called Taylor at home and asked him a series of questions. Is there any mold in the house? Did Taylor travel to a foreign country recently? Did he have any history of taking drugs?
Finally, the doctor came upon the cause: Taylor had recently purchased a feather comforter and feather pillows. He had Feather Duvet Lung disease. The disease is frequently misdiagnosed not only because it is rare, but because medical professionals often don’t ask the right questions.
Without his doctor obtaining an accurate and complete history, Taylor very likely would’ve died from this disease. This tells me that history taking is a pivotal part of patient care. Think of yourself as a sleuth or a detective, like Sherlock Holmes. The truth will be found in asking the right questions.
So what are the major components of history taking? They are: chief complaint; history of present illness; medical history, including past surgeries; ocular history; and social and family history.
This list, published on OphthalmicProfessional.com, is a useful ‘cheat sheet’ when taking a patient’s history.
Key elements of patient history
1. Chief complaint
• History of present illness (minimum of 4 per problem):
1. Location
2. Duration
3. Timing
4. Context
5. Severity
6. Quality
7. Associated signs and symptoms
8. Modifying factors
2. Past ophthalmic history
• Eye diseases/disorders
• Injuries
• Surgeries and treatments
• Current ocular medications (updated at every visit)
3. General medical history
• Review of systems (14 recognized by CMS)
○ Problem-pertinent: must document at least 1
○ Brief: 1-3
○ Extended: 2-9
○ Complete: 10-14
• Medical conditions/serious illnesses
• Surgical history
• Current medications (update required at every visit)
• Allergies
4. Personal, social, family history (minimum of 3)
• Personal
○ Marital status
○ Occupation
• Social history
○ Smoking/tobacco
○ Alcohol use
○ Recreational drug use
• Family history
○ Pertinent disorders (diabetes, hypertension/cardiovascular, cancer)
○ Pertinent ocular disorders (blindness, macular degeneration, cataracts, glaucoma)
In addition to the above information from OphthalmicProfessional, I have included some additional considerations:
Pediatric History Taking requires additional and specific information regarding the child's birth and development including
•Pregnancy & birth
•Developmental
•Medical
•Family
•Social
Under Allergies note that we aren't just talking about medications, we also need to know about the following allergies:
•Ocular Medications
•Systemic Medications
•Contactants
•Ingestants
•Inhalants
•Foods
•Seasonal
•Environmental
•Dyes
Also note that as we are taking a history, to keep in mind that there are different types of vision loss such as:
•Loss of Central Vision
○VA may be better in dim illumination
○VA usually poor
○Sudden onset is usually due to optic nerve or macular origin
○The patient may complain of Distorted Vision which Could be caused by a Macular disorder, High myopia or thick glasses
•Night Blindness
○Can be symptom of RP or Vitamin A deficiency
•Transient Visual Loss
○Always ask if one or Both Eyes - this helps identify the cause
○Does it last Seconds or Minutes?
○May be symptom of Papilledema secondary to increased intracranial pressure, Coronary Artery Disease or Carotid Insufficiency
•Inability to See to the Left or Right
○Patient typically complains of disability with daily tasks or ambulation
○If bilateral: suspect neuro origin on opposite side of Visual field loss
•Patients who complain of an Ascending Veil
○Most Frequently is a sign of a superior retinal detachment
History taking comprises one section of the three core IJCAHPO certification exams, so it’s very important to understand this skill. Remember, although it might feel like prying, you are only trying to do what’s best for the patient and help resolve their medical issue.