History taking in ophalmology

History taking in
Ophthalmology
Assistant professor in Optometry
Ahalia School of Optometry

Why???? History taking
• To establish relationship between examiner and patient
• Can determine etiology of the problem
• Helps to focus on the problem
• Able to capture patients needs and indicators of investigations
• Helps to determine level of impact of the problem in life
• Sometimes helps to diagnose (differential / provisional)with history
alone

Intro’s --- Does it matter??

Introductions
• Should have comfortable & welcoming interior settings
• Be Professional in all the ways(prefer formal)
• Your posture and style matters
• Assisting on and be courteous

Which one is most preferred costume??

What to do?
• Greeting ? …..Yes and introduce yourself
• Should be a good listener
• Good communication skills (verbal and non verbal) (language ?)
• Use only open questions (closed if pt is shy)
• Can ask non clinical (only for relaxation)(it shouldn’t effect your work)
• Should be able to categories relevant/ irrelevant information
• Should provide brief explanation about the examination
• Should take consent before Examination

Not to do
• Never forget your patients name
• Never disclose patient secrets
• keep your professionalism
• Never ask for gifts
• Never discriminate
• Never do any assessments without consent
• Never do anything on a child without guardian consent

Recording
• Keep a recording chart and follow it
• Write legibly
• Always write In SOAP
• S-ubjective
• O-bjective
• A-ssessments
• P-lan
• Should be stored in organized manner

Personal Details
• Record as NOSEAMAD
• Name
• Age
• Address
• Sex
• Ethnicity
• Occupation
• Marital status
• Date of Examination

Demographic details
• Name :only for patient identification
• Age :to categories problem
• Occupation : related problems
• Address : endemic diseases
• Observe patients stature ?, abilities ? and appearances ? (what to or
not to give/ do)
• Ask questions to guardians / attender If necessary

• Avoid Long notes
• Try to write in a common abbreviations
• Should show relevancy to the problem

What to take
1. Presenting complaints /Chief complaints
2. History of present complaint
3. Past ocular (medical) history
4. Systemic History
5. Family history
6. Surgical History
7. Medication history
8. Social history
9. Allergic history

1. Chief complaints (RFV/PC)
• Reason for visit (RFV)
• Patient describe the problem in their own words
• Should be recorded as pt own words
• If have more than one symptom then order it according to the
severity

• It should be Short,Specific, clear sentence
1. Problem
2. Gradually/Sudden?
3. Which Part?
4. Is it in both eyes or only one eye?
5. Since when?
6. Recurrency*

Eg:-
• Bov after using laptop for 2 hours in both eyes since 5 days
• Watering and eye strain sometimes
• Gradual decreased vision in Both eyes, left eye more than right eye
since 2 years
• Gradual decreased vision in (OU), (OS>OD)* 2yrs

2. History of present complaint
• Anything triggers/ relieves symptoms ?
• Any concurrent associated symptoms?
• Have you done anything to subside those symptoms?
• Episodes: Type, Frequency, timing, last subsided
$ - Can use medical terms

Can use LOFTSEA
• Location /laterality
• Onset
• Frequency/occurrence
• Type/severity
• Self treatment and its effectivity
• Effect on Life
• Associated factors

Can use FOLDARQ
• Frequency
• Onset
• Location/ laterality
• Duration
• Associate problems
• Relief
• Quality of symptoms

Pain History OPQRST
1. Onset of disease
2. Position/site
3. Quality/ nature/ character
4. Relation ship to anything/ radiation/ relieving factors
5. Severity
6. Timing (mode of onset)/treatment
Associated symptoms??

Effect on vision
• There are 2 types of complaints
1. Visual complaints
Sudden loss of vision, BOV, blurry, photophobia
2. Non- visual complaints
Discharge, pain itching, swelling
If not already covered in the RFV ask for vision related problem

• Headache , eye strain and asthenopia are related to prolonged near
work, computer use and uncorrect refractive error
• Flashes and floaters are signs of retinal problems (RD)
• Diplopia can be mono/ binocular (Distant/near, intermediate/
direction of gaze)
• Tearing, burning,itching are general symptoms of various ocular
issues.

3. Past ocular (medical)Hx
H/o using glasses/CL
Since,When (last used, last changed), Satisfaction
H/o trauma
Where (Which), When, How,
H/o consultation
Where,When,Prescription if any.
H/o infection
When, occurrence, prescription

• If the patient has already consulted at another hospital and came for
a review then note down every test has been done and its simple
interpretation/ report
• Eg:-
HFA did 1 month back and shows arcuate scotoma in 24-2
H/o under treatment for Herpes virus with antiviral for 2 months
RBS(F/P)-(90/150)mg/dl checked 3 days back

4. Systemic Hx (ROS)
• HTN, Thyroid, Diabetes, Asthma, Artheritis, Stroke, Heart diseases,
kidney, liver diseases
• Any systemic diseases taking medications
• Eg: H/o CKD since 5 years taking/under ( ) medications

Review of Systems (ROS).
• The Review of Systems is list of organ systems that can help the clinician determine the
state of the patient’s general health. Included
Eyes
Ears, nose, and throat
Respiratory
Cardiovascular
Gastrointestinal
Genitourinary
Neurological
Psychological
Musculoskeletal
Skin
Allergic

5. Family Hx
• Myopia (refractive error)
• Glaucoma
• Cancer
• Cataract
• Strabismus
• Asthma, Thyroid disease, Systemic hypertension, Diabetes mellitus,
Vascular disease, infectious diseases
• Same problem as pt
• Specific type of problem (Syndrome)

6. Surgical Hx
• What,Which,When,Where
• Specially ask for any laser treatment has been done (YAG,LASIK)
• Eg:-
• Cataract Sx in RE 1 year back @ ….Hospital
• Kidney transplant 5 years back @.......Hospial

7. Medication Hx
• Always use generic name / trade name
• With Dosage,Timings,And how long
Eg:
1.Tears plus e/d QID in OU *2/12
2. Xalatan E/d OD in OU *4/12 (9.30 PM Yesterday)
3. Rantadine 150mg BD

• Meds like Plaquenil can cause damage in the retina
• Gentamycin can cause epithelial toxicity
• Steroid can cause cataract and glaucoma
• Blood thinners
• Beta blocker users
• Analgesics (sulfa)/ diamox
• Sildanefil citrate (male enhancements) (iris floppy)

8. Social Hx
• What kind of work do you do? (Occupation)
• What are your hobbies? What do you like to do in your spare time?
• Do you drive?
• Do you smoke? Drink alcohol? Use street drugs?
• Computer usage

Allergic Hx
• Ask specially for any medication allergy
• like sulfa / penicillin
• Any kind of systemic allergies with food / environment
• If there write allergic to sulfa drugs since ‘4’ years

Birth history
1. (Full term(FT)/PT),normal delivery (ND)/CD/FD)
2. Birth weight (<1.75) (PT <34 weeks)
3. Incubation (time/ days)
4. Infantal / Maternal infection
5. TORCH’S
6. Delayed milestones/Seizures
7. Parental consanguinity
8. APGAR score

Contact lens Hx
• Type
• Material
• Modality
• Reason for use (RE/Cosmetic)/ Discontinuation
• Usage (Since/last day)
• Sleeping with lenses (Yes/No)
• Using solutions (Type)
• Cleaning regiments and methods
• Lens case (last changed/ last cleaned)

Contact lens Hx
• What type of lens are they?’ (soft, gas permeable, toric, bifocal, etc.)
• How old are your contact lenses?
• Who prescribed the lenses?’
• How long do you usually wear the lenses each day?’ and ‘How many
days per week?’ Also: ‘What is the longest that you will wear your
lenses?’

• When did you put your contact lenses in today?
• What cleaning solutions do you use?
• When was your last contact lens aftercare?
• When is your next aftercare check scheduled?
• Have you had to stop contact lens wear for any reason, even for a
short time?
• When did you first start wearing contact lenses?

History taking in ophalmology

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History taking in ophalmology