Zbieranie wywiadu z zakresu narządów zmysłów | Taking a Sensory Nervous System History

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detachment”: “odwarstwienie siatkówki”, “optic neuritis”: “zapalenie nerwu wzrokowego”, “retinal artery occlusion”: “zamknięcie tętnicy siatkówkowej”, “cataracts”: “zaćma”, “glaucoma”: “jaskra”, “macular degeneration”: “zwyrodnienie plamki żółtej”, “diplopia”: “podwójne widzenie”, “double vision”: “podwójne widzenie”, “cranial nerves”: “nerwy czaszkowe”, “eye muscles”: “mięśnie oka”, “lens abnormalities”: “nieprawidłowości soczewki”, “corneal abnormalities”: “nieprawidłowości rogówki”, “neurological conditions”: “schorzenia neurologiczne”, “stroke”: “udar”, “myasthenia gravis”: “miastenia”, “refractive errors”: “wady refrakcji”, “hearing loss”: “utrata słuchu”, “conductive hearing loss”: “przewodzeniowe uszkodzenie słuchu”, “outer ear”: “ucho zewnętrzne”, “middle ear”: “ucho środkowe”, “sensorineural hearing loss”: “odbiorcze uszkodzenie słuchu”, “inner ear”: “ucho wewnętrzne”, “nerve damage”: “uszkodzenie nerwów”, “infections”: “infekcje”, “noise exposure”: “ekspozycja na hałas”, “presbycusis”: “starcze osłabienie słuchu”, “ototoxic medications”: “leki ototoksyczne”, “tinnitus”: “szumy uszne”, “perception of sound”: “percepcja dźwięku”, “subjective tinnitus”: “szumy subiektywne”, “objective tinnitus”: “szumy obiektywne”, “ringing”: “dzwonienie”, “buzzing”: “brzęczenie”, “hissing”: “syczenie”, “Meniere’s disease”: “choroba Meniere’a”, “aspirin”: “aspiryna”, “NSAIDs”: “niesteroidowe leki przeciwzapalne”, “ageusia”: “utrata smaku”, “loss of taste”: “utrata smaku”, “upper respiratory infections”: “infekcje górnych dróg oddechowych”, “head trauma”: “uraz głowy”, “zinc deficiency”: “niedobór cynku”, “chemotherapy”: “chemioterapia”, “anosmia”: “utrata węchu”, “loss of smell”: “utrata węchu”, “nasal diseases”: “choroby nosa”, “sinus diseases”: “choroby zatok”, “neurodegenerative diseases”: “choroby neurodegeneracyjne”, “Parkinson’s disease”: “choroba Parkinsona”, “Alzheimer’s disease”: “choroba Alzheimera”, “paresthesia”: “parestezje”, “numbness”: “drętwienie”, “tingling”: “mrowienie”, “extremities”: “kończyny”, “nerve compression”: “ucisk nerwu”, “carpal tunnel syndrome”: “zespół cieśni nadgarstka”, “peripheral neuropathy”: “neuropatia obwodowa”, “multiple sclerosis”: “stwardnienie rozsiane”, “photophobia”: “światłowstręt”, “light sensitivity”: “nadwrażliwość na światło”, “eye inflammation”: “zapalenie oka”, “migraine”: “migrena”, “corneal abrasions”: “otarcia rogówki”, “systemic infections”: “infekcje ogólnoustrojowe”, “meningitis”: “zapalenie opon mózgowych”, “eye pain”: “ból oka”, “surface irritation”: “podrażnienie powierzchni”, “dry eyes”: “suche oczy”, “conjunctivitis”: “zapalenie spojówek”, “internal eye causes”: “wewnętrzne przyczyny okulistyczne”, “acute angle-closure glaucoma”: “ostra jaskra zamkniętego kąta”, “balance issues”: “problemy z równowagą”, “coordination issues”: “problemy z koordynacją”, “vestibular system”: “układ przedsionkowy”, “cerebellum”: “móżdżek”, “proprioception pathways”: “szlaki propriocepcji”, “vertigo”: “zawroty głowy”, “inner ear infections”: “infekcje ucha wewnętrznego”, “benign paroxysmal positional vertigo (BPPV)”: “łagodne napadowe położeniowe zawroty głowy”, “vestibular neuritis”: “zapalenie nerwu przedsionkowego”, “central nervous system”: “ośrodkowy układ nerwowy”, “peripheral causes”: “przyczyny obwodowe”, “central causes”: “przyczyny centralne”, “neurological issues”: “problemy neurologiczne”, “onset of vertigo”: “początek zawrotów głowy”, “vestibular issues”: “problemy przedsionkowe”, “fullness in ears”: “uczucie pełności w uszach”, “duration of vertigo”: “czas trwania zawrotów głowy”, “sensation description”: “opis wrażeń”, “spinning sensations”: “wrażenie wirowania”, “peripheral vertigo”: “zawroty głowy obwodowe”, “central vertigo”: “zawroty głowy centralne”, “nausea”: “nudności”, “vomiting”: “wymioty”, “visual changes”: “zmiany widzenia”, “blurriness”: “zamglone widzenie”, “ear symptoms”: “objawy uszne”, “radiation of dizziness”: “rozprzestrzenianie się zawrotów głowy”, “body balance”: “równowaga ciała”, “localized dizziness”: “zawroty głowy miejscowe”, “positional vertigo”: “zawroty głowy zależne od pozycji”, “head position”: “pozycja głowy”, “severity of vertigo”: “nasilenie zawrotów głowy”, “daily activities”: “codzienne aktywności”, “chronic ear infections”: “przewlekłe infekcje ucha”, “sinusitis”: “zapalenie zatok”, “neurological disorders”: “zaburzenia neurologiczne”, “diabetes mellitus”: “cukrzyca”, “neuropathy”: “neuropatia”, “migraine history”: “historia migreny”, “visual disturbances”: “zaburzenia widzenia”, “sensory disturbances”: “zaburzenia czucia”, “family history”: “wywiad rodzinny”, “early-onset hearing loss”: “wczesna utrata słuchu”, “genetic conditions”: “choroby genetyczne”, “medication history”: “historia przyjmowania leków”, “aminoglycoside antibiotics”: “antybiotyki aminoglikozydowe”, “chemotherapy agents”: “leki stosowane w chemioterapii”, “vision-altering drugs”: “leki wpływające na widzenie”, “corticosteroids”: “kortykosteroidy”, “antihypertensive medications”: “leki przeciwnadciśnieniowe”, “neuropathic agents”: “leki neuropatyczne”, “nerve pain”: “ból nerwów”, “mood disorders”: “zaburzenia nastroju”, “occupational noise exposure”: “zawodowa ekspozycja na hałas”, “auditory damage”: “uszkodzenie słuchu”, “vascular changes”: “zmiany naczyniowe”, “optic neuropathy”: “neuropatia nerwu wzrokowego”, “sedentary lifestyle”: “siedzący tryb życia”, “neuropathic symptoms”: “objawy neuropatyczne”, “physical activity”: “aktywność fizyczna”, “drug allergies”: “alergie na leki”, “allergic reactions”: “reakcje alergiczne”, “nasal congestion”: “zatkanie nosa”, “food allergies”: “alergie pokarmowe”, “chemical exposure”: “ekspozycja na chemikalia”, “solvents”: “rozpuszczalniki”, “pesticides”: “pestycydy”, “neurotoxic effects”: “neurotoksyczne działanie”, “poor air quality”: “niska jakość powietrza”, “heavy metal exposure”: “ekspozycja na metale ciężkie”, “lead”: “ołów”, “mercury”: “rtęć”, “neurotoxicity”: “neurotoksyczność”, “consultation summary”: “podsumowanie konsultacji”, “pain”: “ból”, “halos”: “poświaty”, “flashes”: “błyski”, “binocular”: “dwuoczny”, “monocular”: “jednooczny” }; // Normalize keys in the dictionary const normalizedWordsToTooltip = {}; for (const [key, value] of Object.entries(wordsToTooltip)) { const cleanedKey = key.replace(/(.*?)/g, ”).trim(); // Remove anything in parentheses normalizedWordsToTooltip[cleanedKey.toLowerCase()] = value; } function processNode(node) { if (node.nodeType === Node.TEXT_NODE && node.nodeValue.trim()) { let content = node.nodeValue; // Regex to match only the main words (ignores parentheses) const regex = new RegExp( `b(${Object.keys(normalizedWordsToTooltip).join(‘|’)})b`, ‘gi’ ); if (regex.test(content)) { const wrapper = document.createElement(‘span’); wrapper.innerHTML = content.replace(regex, (match) => { const tooltip = normalizedWordsToTooltip[match.toLowerCase().trim()]; return `${match}`; }); node.replaceWith(wrapper); } } else 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Szacowany czas lekcji: 13 minut
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Opening Consultation

Before starting, review the patient’s medical records for relevant musculoskeletal history if available.

Confirm the patient’s identity politely.

Teraz ty powiedz:

  • Mr. Jones? This way, please.
  • Ms. Jones? Please come in.
  • Could I please confirm your full name and date of birth?
  • Just to confirm, your name and date of birth?
  • Your full name and date of birth, please.

Introduce yourself warmly, stating your name and role.

Teraz ty powiedz:

  • Hello, I’m Dr. Jones. How can I help you today?
  • Good morning/afternoon, I’m Dr. Jones. What brings you in today?
  • Hi, I’m Dr. Jones. What would you like to discuss today?

Chief Complaint (CC)

The Chief Complaint (CC) represents the primary sensory-related symptom or concern a patient presents with during a consultation. Sensory system complaints may involve issues with vision, hearing, taste, smell, or touch, each associated with distinct diagnostic clues. Here are some common complaints and their descriptions within the sensory system:

ComplaintDescription
Vision LossVision loss may be sudden or gradual and can affect one or both eyes. Acute vision loss might suggest conditions such as retinal detachment, optic neuritis, or vascular events like retinal artery occlusion. Gradual vision loss is often linked to cataracts, glaucoma, or macular degeneration. The extent, duration, and associated symptoms (e.g., pain, halos, flashes) are key in assessment.
DiplopiaDouble vision, or diplopia, can be binocular (present with both eyes open) or monocular (persists with one eye closed). Binocular diplopia often indicates issues with the cranial nerves or eye muscles, while monocular diplopia may be linked to lens or corneal abnormalities. Causes range from neurological conditions, such as stroke or myasthenia gravis, to refractive errors.
Hearing LossHearing loss may be conductive (obstruction or damage in the outer/middle ear) or sensorineural (inner ear or nerve damage). Common causes include infections, noise exposure, aging (presbycusis), or ototoxic medications. The presence of ear pain, tinnitus, or dizziness helps refine the differential.
TinnitusTinnitus, or the perception of sound without an external source, may be subjective or objective (heard by both patient and examiner). It often presents as ringing, buzzing, or hissing. Potential causes include noise exposure, age-related hearing loss, Meniere’s disease, and certain medications (e.g., aspirin, NSAIDs).
AgeusiaLoss of taste, known as ageusia, may result from upper respiratory infections, head trauma, or certain medications. Distinguishing between true taste loss and loss of smell (which contributes significantly to flavor) is essential. Causes also include zinc deficiency, chemotherapy, or nerve damage affecting taste perception.
AnosmiaAnosmia, or loss of smell, can stem from nasal/sinus diseases, head trauma, or neurodegenerative diseases like Parkinson’s or Alzheimer’s. It may be complete or partial and is often temporary following viral infections but warrants further investigation if persistent.
Numbness or TinglingNumbness or tingling (paresthesia) may affect any body area, commonly in the extremities. It could indicate nerve compression (e.g., carpal tunnel syndrome), peripheral neuropathy, or conditions like multiple sclerosis. The location, onset, and duration help narrow down the cause.
PhotophobiaPhotophobia, or light sensitivity, is often associated with eye inflammation, migraine, or corneal abrasions. It may also accompany certain systemic infections or neurological conditions, like meningitis. Evaluation includes assessing concurrent symptoms, such as headache, vision changes, or redness in the eyes.
Pain in or Around the EyeEye pain can be due to surface irritation (e.g., dry eyes, conjunctivitis) or internal causes (e.g., glaucoma, optic neuritis). Sharp pain with vision loss is concerning and may indicate emergent conditions like acute angle-closure glaucoma.
Balance and Coordination IssuesDifficulties with balance or coordination may indicate issues within the vestibular system, cerebellum, or proprioception pathways. Conditions like vertigo, inner ear infections, or neurological diseases (e.g., stroke, multiple sclerosis) are potential causes. Patients often describe dizziness, unsteadiness, or vertigo sensations.

History of Present Illness: Vertigo

Vertigo is a sensation of spinning or dizziness, often linked to dysfunctions in the vestibular (inner ear) system or the central nervous system. A structured approach like OLD CARTS aids in gathering essential information to differentiate between peripheral and central causes, including conditions like benign paroxysmal positional vertigo (BPPV), vestibular neuritis, Meniere’s disease, or even neurological issues such as stroke.

OLD CARTS Assessment of Vertigo

  • O – Onset: Knowing how and when vertigo started is key. Sudden-onset vertigo may suggest vestibular issues like BPPV, whereas a gradual onset may be more consistent with neurological causes.

Teraz ty zapytaj – Onset:

  • When did you first start experiencing dizziness or imbalance?
  • Did the dizziness come on suddenly, or has it developed gradually over time?
  • Was there any specific movement or activity that seemed to bring on the first episode?
  • Have you had similar episodes of dizziness in the past?
  • L – Location: While vertigo does not have a “location” in the traditional sense, identifying whether symptoms are limited to vertigo or include other sensory impairments (like hearing loss or tinnitus) can help narrow down causes.

Teraz ty zapytaj – Location:

  • Do you notice any changes in your ears, such as ringing, pressure, or hearing loss, along with the dizziness?
  • Does the sensation feel like it’s affecting your head specifically, or do you feel it throughout your whole body?
  • Is there any feeling of fullness in your ears during these episodes?
  • D – Duration: The duration of each vertigo episode can guide diagnosis. Brief episodes lasting seconds might suggest BPPV, while episodes lasting hours to days are more characteristic of conditions like Meniere’s disease or vestibular neuritis.

Teraz ty zapytaj – Duration:

  • How long do these episodes of dizziness usually last?
  • Is the sensation of dizziness constant, or does it come and go?
  • Have you noticed any change in the frequency or duration of these episodes over time?
  • C – Character: Understanding the sensation (spinning, tilting, or swaying) provides clues. Spinning sensations are more commonly associated with peripheral vertigo, while central vertigo may produce sensations like tilting or rocking.

Teraz ty zapytaj – Character:

  • How would you describe the sensation—does it feel like spinning, swaying, or a general lightheadedness?
  • Do you feel as though you are moving or that the room around you is moving?
  • Is the dizziness intense, or is it more of a mild imbalance?
  • A – Associated Symptoms: Additional symptoms like nausea, vomiting, hearing loss, tinnitus, or double vision can point to specific diagnoses. For example, hearing loss and tinnitus are often associated with Meniere’s disease, while double vision or slurred speech may suggest a central (neurological) cause.

Teraz ty zapytaj – Associated Symptoms:

  • Do you experience nausea, vomiting, or a need to sit down when these symptoms occur?
  • Have you noticed any visual changes, like blurriness or double vision?
  • Are you also experiencing ear symptoms, such as ringing, pressure, or changes in hearing?
  • R – Radiation: Although vertigo does not “radiate” like pain, it is important to determine if the dizziness affects the entire body’s balance or if it’s more localized, such as feeling unsteady while walking.

Teraz ty zapytaj – Radiation:

  • Does this sensation affect your balance, making it difficult to stand or walk steadily?
  • Would you say the dizziness impacts your entire body, or does it feel more centered in your head?
  • T – Timing: Timing and frequency can reveal patterns. Positional vertigo is typically triggered by changes in head position, while other types may occur at random or be influenced by stress or environmental factors.

Teraz ty zapytaj – Timing:

  • Are there specific times of day or activities that seem to make the dizziness worse?
  • Does changing positions, like standing up quickly or turning your head, make the sensation more intense?
  • Is there anything that consistently brings on the dizziness or makes it more severe?
  • S – Severity: Assessing the severity and impact on daily activities helps understand how debilitating the vertigo is. Severe cases may prevent the patient from standing or walking safely, requiring urgent management.

Teraz ty zapytaj – Severity:

  • On a scale of 0 to 10, how intense is the dizziness during an episode?
  • Does the dizziness affect your ability to perform daily tasks or activities?
  • Has this sensation impacted your quality of life or ability to function normally?

Past Medical History

Understanding a patient’s past medical history is essential for identifying sensory system concerns that may predispose them to current sensory complaints:

  • Chronic Ear Infections: Recurrent ear infections may lead to hearing loss or balance issues. Understanding a history of such infections helps in evaluating persistent ear-related symptoms.
  • Sinusitis: Chronic sinus infections can cause changes in smell or taste and may impact the middle ear, affecting hearing and balance.
  • Neurological Conditions: A history of neurological disorders, such as multiple sclerosis or Parkinson’s disease, may predispose the patient to sensory disturbances, including vision or hearing problems.
  • Diabetes Mellitus: Diabetes can lead to neuropathy, often affecting peripheral sensory function, particularly in the feet and hands. Loss of sensation or tingling may be relevant in this context.
  • Meniere’s Disease: This inner ear disorder often presents with episodic vertigo, tinnitus, and fluctuating hearing loss, impacting balance and auditory function.
  • Migraine History: Patients with a history of migraines may experience sensory changes, such as visual disturbances or aura, as part of their migraine episodes.

Teraz ty zapytaj – Past Medical History:

  • Have you had chronic ear infections or issues with your ears?
  • Do you have a history of sinus infections or sinus-related issues?
  • Have you been diagnosed with any neurological conditions, such as multiple sclerosis or Parkinson’s disease?
  • Do you have diabetes, and have you experienced numbness or tingling?
  • Have you been diagnosed with Meniere’s disease or experienced episodes of vertigo?
  • Do you have a history of migraines, especially those with visual or sensory disturbances?

Family History

Family history provides insights into genetic predispositions related to sensory disorders, which may guide the clinical approach:

  • Hearing Loss: Family history of early-onset hearing loss or genetic conditions associated with hearing impairment can indicate an inherited component.
  • Vision Disorders: Conditions like glaucoma or macular degeneration often have genetic components. Understanding the family history can help assess risk factors for visual impairment.
  • Neurodegenerative Diseases: Family history of neurodegenerative disorders, such as Alzheimer’s or Parkinson’s disease, can provide insight into potential risk for sensory or cognitive disturbances.

Teraz ty zapytaj – Family History:

  • Is there a family history of early-onset hearing loss?
  • Does anyone in your family have a history of vision disorders, like glaucoma or macular degeneration?
  • Are there neurodegenerative diseases, such as Alzheimer’s or Parkinson’s, in your family?

Medications

Medication history helps assess potential side effects or drug interactions that might affect sensory functions:

  • Ototoxic Medications: Certain medications, such as aminoglycoside antibiotics and chemotherapy agents, are known to cause hearing loss or balance issues.
  • Vision-Altering Drugs: Drugs like corticosteroids and some antihypertensive medications may lead to visual disturbances, including blurriness or photophobia.
  • Neuropathic Agents: Medications for neuropathic pain or mood disorders may cause side effects impacting sensory perception, such as tingling or numbness in extremities.

Teraz ty zapytaj – Medications:

  • Are you currently taking any medications that affect hearing or balance, such as specific antibiotics?
  • Have you been prescribed any medications that might cause visual disturbances?
  • Are you taking any drugs for nerve pain or mood issues that could cause tingling or numbness?

Social History

A thorough social history identifies lifestyle and environmental factors influencing sensory health:

  • Occupational Noise Exposure: Long-term exposure to loud sounds, such as in construction or factory work, is a leading cause of hearing loss.
  • Recreational Activities: Frequent use of headphones at high volumes or exposure to loud music venues can contribute to auditory damage.
  • Smoking and Alcohol Use: Smoking and alcohol use are linked to vascular changes that may affect vision and contribute to conditions such as macular degeneration and optic neuropathy.
  • Physical Activity: A sedentary lifestyle may exacerbate neuropathic symptoms, especially in individuals with diabetes, while physical activity supports overall neurological health.

Teraz ty zapytaj – Social History:

  • Have you been exposed to loud noises regularly, such as in construction work or factory settings?
  • Do you often listen to loud music, especially with headphones?
  • Do you smoke or consume alcohol regularly?
  • How physically active are you, and do you exercise regularly?

Allergies

Assessing allergies is crucial for understanding potential triggers that may contribute to sensory symptoms, particularly in cases involving allergic reactions affecting the nose, throat, or skin:

  • Drug Allergies: Allergic reactions to specific medications, such as antibiotics or NSAIDs, may cause or exacerbate hearing or vision disturbances.
  • Environmental Allergies: Exposure to allergens such as pollen, mold, or dust can impact nasal and sinus health, potentially affecting smell, taste, and, indirectly, hearing through sinus congestion.
  • Food Allergies: Some patients report sensory disturbances as part of an allergic response to certain foods, impacting taste and smell or causing a tingling sensation.

Teraz ty zapytaj – Allergies:

  • Do you have any known drug allergies, especially to medications that could affect sensory functions?
  • Are you sensitive to common environmental triggers like pollen, mold, or dust?
  • Do you experience sensory changes related to any food allergies or sensitivities?

Environmental and Occupational Exposures

Environmental factors and occupational exposures can have a significant impact on sensory health, particularly for hearing, vision, and balance:

  • Chemical Exposure: Prolonged exposure to certain chemicals, such as solvents or pesticides, may cause neurotoxic effects, impacting sensory function.
  • Poor Air Quality: Environments with pollutants, mold, or dust can exacerbate sinus issues and respiratory conditions, affecting the sense of smell and taste.
  • Heavy Metal Exposure: Work environments with heavy metals, like lead or mercury, may contribute to neurotoxicity, affecting sensory perception, balance, and overall neurological health.

Teraz ty zapytaj – Environmental and Occupational Exposures:

  • Are you regularly exposed to chemicals, like pesticides or cleaning agents?
  • Is there any mold or poor air quality in your home or workplace?
  • Have you worked with heavy metals, such as lead or mercury, in your occupation?

Closing the Consultation

Summarize the main points discussed during the history-taking to confirm understanding and ensure no details were missed.

Teraz ty powiedz:

  • Let me summarize what we’ve discussed so far to make sure I have everything correct.
  • To confirm, you’ve mentioned [key symptoms or points]. Does that sound accurate?
  • Is there anything important that we haven’t covered?
  • Before we proceed, is there anything else you’d like to add or clarify?
  • Thank you for sharing all these details; it will help us plan the next steps effectively.

Ask the patient if they have any remaining questions or concerns before moving forward with the examination.

Teraz ty powiedz:

  • Do you have any other questions or concerns before we start the examination?
  • Is there anything else you’d like to discuss before we begin the physical exam?