Case History

Question 1

what is a case history?

Answer 1

patient own account of what the problem is.

Question 2

You should address patient formally by last name; make eye contact and listen attentively.
Don’t use optometric jargon.

True or False

Answer 2

True.

Question 3

Always use what color pen and never use what type of paper? why?

Answer 3

black pen always and never use thermal paper because it makes ink fade.

Question 4

How many sections is case history broken into? Name them.

Answer 4

5 sections:

1) Chief and secondary complaint
2) Patient Info
3) Ocular Health= personal and family (DDTO)refractive and visual (first and current Rx) and Health, allergies
4) Systemic Health= personal and family (DDTO)
5) Summary (wrap up)= is the pt oriented x3 (time, place, person) and what is the mood/affect of the pt (SAGA: sad, angry, agitated, aggressive).

Question 5

what does DDTO mean?

Answer 5

Diagnosis, Date or duration, Treatment, Outcome

Question 6

Define FODLARS. What does each component mean?

Answer 6

• FODLARS- ask open ended questions; use separately for both chief and secondary complaint
o Frequency: chronic, intermittent
o Onset
o Duration
o Location: where are you when it happens, where does it occur in your vision
o Associate factors: what are you doing when it happens, what triggers it
o Relief: what makes it better
o Severity: degree of severity
o Additional complaints unrelated to chief complaint (secondary complaint)

Question 7

what “additional info” can you take to help with case history from patient?

Answer 7

occupation, 
hobbies, 
sports, 
special eye wear needs or requirements (glasses, contacts, protective eye wear, driving)
substance abuse

Question 8

what is the most important outcomes for you as the doctor dealing with a patient?

Answer 8

The most important outcomes are:
DIFFERENTIAL DIAGNOSIS
TENTATIVE DIAGNOSIS
TESTING STRATEGY= which tests do I need and which test do I not need.

Question 9

Visual/ocular
Refractive
Glasses
Distance, Near, Intermediate, Sunglasses
Contact lenses
Disposable/Non-disposable
Soft/rigid/hybrid/bifocal/monovision
Binocular vision
Visual skills, strabismus, therapy, rehabilitation
Ocular health
General/systemic health
Neurologic
Systemic health
Trauma/Injury
Comprehensive Care on a Routine basis

These are examples or differential or systemic diagnosis?

Answer 9

systemic diagnosis

Question 10

Secondary complaints are usually related to Chief complaint. T or F

Answer 10

False. They are not usually related but they can be sometimes.

Question 11

Secondary complaint cannot turn into primary complaint. T or F

Answer 11

False. Yes it can.THE PATIENT CHIEF COMPLAINT MAY NOT REMAIN THAT CHIEF COMPLAINT. IT CAN CHANGE BASED ON WHAT YOU FIND DURING EXAM.
FOR EXAMPLE: PATIENT COMPLAIN OF LOSE GLASSES AND THEN YOU FIND A TUMOR. The more serious tumor takes precedence and is now primary.

Question 12

Tentative Diagnosis and treatment goes under “whole person approach”.
T or F

Answer 12

True

Question 13

Substance abuse history would be recorded under Systemic Health (Medical Health) Category. T or F

Answer 13

True

Question 14

These are all apart of the what for a patient?
o	Caring professional
o	Privacy
o	Non-judgmental
o	Non-verbal cues
o	Tentative diagnosis
	Refractive
	Ocular health issues from history
	Functional diagnosis from complaints and performance

Answer 14

Holistic or Whole person approach