History taking in clinical ophthalmology

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  • 1. Ahmad Abid bin Abas 07-5-2Ahmad Asyraf bin Mohamed 07-5-3
  • 2.  Preparation Brief Introduction of yourself to patient Confidentiality Documentation Communication
  • 3.  Personal Data : - Name (for identification, filing system, friendly) - Age (age related diseases-child : congenital diseases, old : senile diseases) -Sex (sex related diseases) -Address (endemic diseases, social status) -Occupation (occupation related diseases, visual needs)
  • 4.  Chief Complain (c/o) : - in Arabic/Malay , in patient’s words -don’t forget duration of c/o -don’t use diagnostic words. -return and correct unrelated complaints -if more than one, arrange by chronological and by importance.
  • 5.  Type of complaints : 1) Visual complaints : -(sudden loss of vision, diminution of vision, blurring, photophobia etc..) 2) Non-Visual complaints : -(discharge, pain, itching, swelling etc..)
  • 6. 1) Describe each complaints in scientific words2) Analyse each complaints as regards; ◦ Onset ◦ Course ◦ Side ◦ Duration ◦ Associated symptoms ◦ Previous medical advice and medication
  • 7. 1) Ask if similar or related problems haveexisted before.-Chronological order the major illness andmajor operations- previous eye surgery2) Past use of medications.3) History of previous glasses.4) Diabetes Mellitus and Hypertension5) Systemic Illness
  • 8. Ask if any other member of the family havesimilar condition or other eye related diseases.