PATIENT PROFILE & CASE HISTORY Manish Khanna B.Optom 13th October, 2012
Patient Profile Name of patient Address Contact details Age Occupation Race / ethnicity Gender Hobbies / lifestyle Education level
Case History Communication The chief complaint Patient’s ocular history Patient’s ocular health Medications Allergies Family ocular and medical history Vocational and recreational visual requirement
Main Objectives of aCase History To elicit reasons for visit To ascertain patient’s expectations To acquire relevant background information To determine the specific tests or procedures that should be performed during the examination To form a tentative diagnosis
Communication Greet the patient with confidence Introduce yourself, be professional Establish a relationship of trust Show genuine interest Be courteous and respectful Ask open-ended questions “What difficulties are you experiencing with your vision?”
Chief Complaint The chief complaint is usually the primary reason for the patient seeking consultation “What is the reason for your visit?” “What brings you to the practice today?” “What seems to be the problem?”
Description of the complaint/symptoms: Headache Duration Relief or remitting factors Frequency Associated sign and symptoms Location: Temporal, Frontal, and Occipital, etc. Laterality: RE, LE or BE? Onset Pain Prescription medication Exacerbating factors Severity
Description of the complaint/symptoms: Blurred Vision Duration Relief or remitting factors Frequency Associated sign and symptoms Location: DV, NV or Both? Laterality: RE, LE or BE? Onset Pain Prescription medication Exacerbating factors Severity
Likely Aetiologies for BlurredVision: Ametropia/ presbyopia Night myopia Malingering Ocular disease conditions, e.g. cataracts, retinal disease, optic nerve diseases Amblyopia Accommodative dysfunction Constant distance and near blur could be refractive such as astigmatism Constant distance blur could be refractive such as myopia Intermittent near blur could be refractive such as moderate hyperopia Constant near blur - presbyopia or high hyperopia There may be other causes of blur or even multiple causes compounding one another Other chief complaints are explored in a similar manner.
Patient’s Ocular History Last eye examination Previous ocular disease or trauma / injury Any history of ocular surgery Any history of strabismus or amblyopia Previous prescriptions including spectacles and contact lenses
Patients Medical History Heart or kidney disease High blood pressure Diabetes Arthritis General fitness Headaches (those not related to vision) Any other systemic condition Last medical examination
Medications and Allergies Drug Name Purpose Dosage Compliance Side effects Duration of the treatment Cause of allergy: Environmental or medication
Family Ocular and MedicalHistory Family ocular history: glaucoma, low vision / blindness, significant refractive errors (exclude presbyopia) Family health history: heart / kidney disease, high blood pressure, diabetes, etc. Patients with any family ocular / medical history of disease should receive a comprehensive ocular / health examination to rule out the presence of the same condition in the patient.
Vocational and RecreationalVisual Requirements Lighting conditions Computer monitor use Print size(s) Working distance(s) Safety / eye hazards In certain specialty areas, like that of low vision for instance, these aspects of the case history are especially important to ensure that the individual is able to remain as productive and functional as possible
Common Abbreviations Used InRecording The Case History Px (or Pt) Patient Rx Prescription DS Sphere DC Cylinder CC Chief Complaint h/a Headache DV Distance Vision NV Near Vision R Right L Left RE (or OD) Right Eye LE (or OS) Left eye B (or binoc) Binocular BE Both eyes c With s Without 1/52, 3/52 1 week, 3 weeks 3/12, 6/12 3 months, 6 months Increase Decrease OK Okay Sx Symptoms FOH Family ocular history FMH Family medical history GH General health Meds. Medication LEE Last eye examination LME Last medical examination Occ. Ointment Gutt. Drops BID Twice a day TID Three times a day