Case History

Question 1

Case History tid bits

Answer 1

• identify patient
• Why are they there?
• gather SUBJECTIVE information to drive exam and make OBJECTIVE evaluations
• history continues through exam

Question 2

What does the exam conclude with?

Answer 2

• diagnosis-identification of specific clinical problem by doctor
• management- plan of action to address problem(ALWAYS tie back to chief complaint)

Question 3

Case History Content

Answer 3

-Demographic data
-Chief complaint (secondary complaints?)
-Background info
ocular/medical history
medications
family history
social history
review of systems

Question 4

Demographic data

Answer 4

Age-certain ages are more normal for certain diseases
-first thing recorded
Gender- sex-linked hereditary diseases(color)
-men and women have different lifestyles
Race- some diseases are more prevalent in certain races (sickle cell)

Question 5

Traditional clinical presentation of a patient

Answer 5

“Patient is a AGE RACE GENDER who presents with”

Question 6

Chief Complaint

Answer 6

• the reason the patient came in
• concise and in their words
• use open ended questions to figure it out
• NEVER ROUTINE EYE EXAM
• ask follow up questions

Question 7

History of present illness

Answer 7

-follow up to chief complaint
-characterize the chief complaint
F-frequency
O-onset
L-location
D-duration
A-associative factors
R-relief
Q-quality (severity)

-periods of exacerbation and remission

Question 8

Secondary Complaints

Answer 8

• -law of parsimony-if one diagnosis fits a group of signs or symptoms, it is the best choice of a working diagnosis
• blurred vision is chief complaint, headache is secondary complaint

Question 9

Ocular History

Answer 9

• last eye exam(where,when,results)
• History of corrective lenses or treatment(wearing pattern, when first perscribed, when were you percribed habitual)
• history of ocular surgery
• history of ocular disease

Question 10

Medical History

Answer 10

• SIGNIFICANT past illnesses, injuries, past surgeries

- consequences or outcome of above

Question 11

Medications

Answer 11

• prescriptions(name, dosage, reason for taking, duration of taking)
• over the counter
• recreational (possible diseases)

Question 12

Family Ocular History

Answer 12

• hereditary ocular conditions
• transmitted ocular conditions
• endemic ocular conditions
• OPEN ENDED
• REFRACTIVE HISTORY DOES NOT MATTER
• CATARACTS DOES NOT MATTER

Question 13

Family Medical History

Answer 13

• systemic hereditary conditions
• transmitted systemic conditions
• mostly immediate family
• DON’T CARE IF AUNT HAS HIGH BLOOD PRESSURE

Question 14

Social History

Answer 14

• learn about the patient’s lifestyle
• occupation:work conditions, work ocular requirements
• Alcohol/drugs/tobacco

Question 15

Review of Systems Categories

Answer 15

CURRENT STATUS

• ear, nose, throat
• cardiovascular
• endocrine
• dermatological
• gastrointestinal
• genitourinary
• psychiatric

“how is your current health?”

Question 16

How to approach the patient

Answer 16

• open-ended questions
• minimal direction(don’t lead them to an answer)
• active listening

Question 17

Problem focused exam

Answer 17

• DO NOT NEED TO REPEAT ALL ASPECTS OF HISTORY OR REVIEW OF SYSTEMS
• just ask if any changes since last visit
• patient returning for dilation, red-eye, treatment
• sudden onset of red eye

Question 18

Common Chief Complaints

Answer 18

• blurred vision
• eyestrain
• headache
• twitching of eyelid
• loss of vision
• flashers/floaters