HISTORY TAKING PPT BY DR JITENDRA SINGH, IGEHRC, GURUGRAM, INDIA

1. INDIRA GANDHI EYE HOSPITAL
AND RESEARCH CENTRE
GURUGRAM, HARYANA
DR. JITENDRA SINGH
IGEHRC
HISTORY TAKING

2. Introduction
 Patient history is the key to an efficient,
comprehensive, problem orientated examination of
patient and resolution to the patient’s problem.
 Art more than a science.
 Problem solving exercise.
 Pattern matching.
 Dynamic interaction that continues throughout the
examination.
 Social interaction.

3. Point to consider
 Must listen to patient attentively.
 Try to understand.
 Do not judge.
 Corelate things.

4. CONTENT
1. Demographic Data
2. Chief complaint
3. History of present complaints.
4. Secondary complaint
5. Ocular History
6. Medical History
7. Drug and medication
8. Family ocular History

5. CONTENT
9. Family medical History
10. Social History
11. Review of systems
12. How to approach the patient?
13. Some common signs and symptoms.

6. Demographic Data
Introductory information about the patient.
1. Age
2. Gender
3. Address

7. Chief complaint
 Main reason that the patient has come to you.
 Limited to 1 or 2 sentence.
 Record in patient’s words.
 Do not interpret.
 Open ended question works best.
 Ask what is bothering them?
 Why they have made the appointment?

8. History of present complaint
That point at which clinician details the chief complaint of
patient.
 Complain is specified using the following categories:-
 Location
 Severity
 Character of a sign or symptom
 Nature of onset
 Duration
 Frequency
 Exacerbation and remission
 Relationship to bodily activities or functions
 Accompanying sign and symptoms.

9. Secondary Complaints
May or may not be a part of a complaint.

10. Ocular History
1- H/O spectacle wear
1st time when the lenses were prescribed.
Wearing time
Wearing schedule
2- Last eye examination
Date
Result of last eye examination
Suggested treatment
3- History of any ocular surgery

11. Ocular History
4-H/O ocular disease or trauma
Type of episode
Treatment given
Sequelae

12. Medical History
 Diabetes
 Hypertension
 Cardiovascular disease
 Allergy
 Any past illness or surgery

13. Drug and Medications
 Medicine taken for a particular disease can
indicate its
-Nature
-Course
-Ocular complications
 Recreational drugs
 Drug abuse- Routes of administration

14. Family Ocular History
Hereditary conditions:-
-Glaucoma
-RP
-Colour vision degeneration
-Hypertension
-Diabetes Mellitus etc.
 Conditions that might get transferred from one person
to other
Ex- Toxoplasmosis
Condition that are endemic
Ex- Histoplasmosis

15. Family Medical History
 Hereditary conditions
 Conditions that might get transferred from one
person to other.

16. SOCIAL HISTORY
1. Occupation
2. Marital Status
3. Avocational Interests
4. Alcohol use
5. Tobacco use
6. Smoking

17. Review of System
1. Ear, Nose, Throat
2. Cardiovascular
3. Endocrine.
4. Dermatological
5. Gastrointestinal
6. Genitourinary
7. Psychiatric

18. How to approach a patient
1. Open Ended question Patient should be asked
questions which they can answer in more than a
yes or no
2. Do not interrupt storytelling
3. No judgement
4. Minimal Direction
5. Active listening

19. Common Ocular Complaints
 Blurred vision at near point
 Nonspecific ocular discomfort and fatigue
 Burning or tearing of eyes
 Blurred vision at far point
 No complaint: request for routine checkup, new frame, etc.
 No complaint: broken or lost lenses or spectacles
 Headache(relationship to eyes not specified)
 Headache following use of eyes
 Conjunctivitis or blepharitis (crusting And flaking)
 Twitching of lids, itching of eyes
 Photophobia

20. Common Ocular Complaints
 Ocular pain
 Loss of vision (uniocular, binocular, and scotomas)
 Exophthalmos (uniocular and binocular)
 Diplopia
 Anisocoria
 Photopsia and halos
 Strabismus
 Lumping of words and other difficulties when reading
 Disturbance of color vision
 Vertigo
 Foreign body in eye.

21. THANK YOU