Case History

Question 1

• Aids in establishing the relationship
  • Puts a patient at ease
  • Sense mood/ affect/ orientation

Answer 1

Greet the Patient

Question 2

• it is the first and, many times, the most important aspect of the optometric exam
  - allows for an “organized discussion” with the patient

  - informs the clinician why the patient sought professional care
  - directs the clinician in prioritizing the exam

Answer 2

Patient’s History

Question 3

1. Does the patient have a problem
   2. What is the specific problem?
   3. What is or will be the effect of the problem on the patient’s performance or physical status?

Answer 3

3 essential questions that must be answered:

Question 4

1. The history never ends
   2. The history should be complete
   3. Listen carefully to the patient

Answer 4

3 maxims must be heeded:

Question 5

Name: Gender: Age: Civil Status:

  Address:                                                                          Email:

  Phone No.                                                                       Mobile No.

  Occupation/ Course ( if studying)

  Hobbies/ Vocation

_______________________________________________

Answer 5

Basic Demographic Data / Patient’s Profile

Question 6

Remember to think of the patient as more than a pair of eyes that walks in
Want to make an overall general observation of the patient including;
Gait
Head position
Facial symmetry
Skin color
Speech
Appearance

Answer 6

General Observation/ Initial Observation

Question 7

1. comprehensive eye exam
2. follow-up
3. change of prescription
4. for employment

Answer 7

Reasons for visit

Question 8

1. One or more symptoms/concerns for which patient is seeking advice
2. Primary reason the patient is seeking care
3. Typically elicited by such questions as:
   • “What seems to be the problem?”
   • “What is the reason for this visit?”
   • “What brings you to the office today?”
4. To further expand the chief complaint, a series of questions are asked to further expand on the complaint
   • History of Present Illness

Answer 8

Chief Complaint and Associated Complaints

Question 9

ach letter stands for a question to consider when documenting symptoms.

F - frequency how often do you experience? Constant or intermittent? if intermittent, how many times a day

O - onset the first appearance of the illness . When do you first experienced it? gradually or suddenly

                          at what point during the day?

L - location where is the site of the problem? If a headache or eye pain, localize more specifically. It can be frontal, parietal, temporal, occipital.

D - duration length of time it has been present, how long has the problem been an issue? How long symptoms last when they occur- hours, minutes, days

Answer 9

CHIEF COMPLAINT

Question 10

Are other complaints that accompanied the Chief complaints

Answer 10

Associated Complaints

Question 11

Personal History

Are history of the eye diseases and spectacles with inclusion of dates

Questions like;
Time since last eye exam?

Any recurring problems?

How long has patient been wearing glasses? How many pairs of eyeglasses

Any prior ocular disease, trauma, or surgery?

Answer 11

Ocular and Spectacle Hx

Question 12

History of poor vision in the family may help determine an accurate diagnosis
Questions like “Has anyone in your family had any eye disease?

Certain eye conditions tend to “run in families” such as;

high refractive error

glaucoma

age related macular degeneration

strabismus

Answer 12

Family history

Question 13

Personal History

Importance of medical history:
To know if there’s systemic disease that maybe resulting in an ocular manisfestation
Systemic diseases also help identify possible medications

Many patients don’t see the connection between their systemic health and their eye, so they will not mention them. Or if patient is currently medicated they don’t feel the condition is worth mentioning.

It is often necessary to ask patients about their medical history and give examples of conditions that you are interested in.
E.g. “Do you have any health problems such as diabetes, hypertension, thyroid?

Family History
Certain systemic diseases have a genetic predisposition
Diabetes

Hypertension

High Cholesterol

Cancer

Answer 13

Medical Histories including Obstetrics for Pedia Px

Question 14

Numerous medications may manifest adverse visual or ocular effects

Steroids: glaucoma, cataracts
Allergy medications: dry eyes, CL problems
Plaquenil (arthritis medication): cornea and retina changes

Patients often think that because they are taking medications to control systemic diseases that it means those conditions don’t exist.
Not until you ask about their medications do you find out they have thyroid disease or hypertension.
Many female patients don’t consider birth control pills as a medication.

Questions like, what medicine are you taking? for what sickness? what is the dosage?

Answer 14

History of Medications and Hypersensitivities