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HISTORY TAKING IN
OPHTHALMOLOGY
R ANUDEEP
IMPORTANT OR NOT
• Yes , History is important in all medical
cases
• Which history we are taking depends on
the condition (presenting complaint)
• Ocular history taking also follows same
guidelines
Importance of history taking
• Obtaining an accurate history is the critical first
step in determining the etiology of patient’s
problem
• A large percentage of the time ( around 70 % )
you will actually be able to make a diagnosis
based on the history alone
Structure of history
• Introduction and describing aim &
objectives
• Chief complaint
• History of present illness
• Past medical / surgical / laser history
• Systemic history
• Family history
Structure of history
• Birth history
• Drug history
• Social history
• Present medical history
• Allergy history
• Psychosocial Assessment
GREETING
• WISH TO THE PATIENT - GOOD
MORNING SIR (OR) MADAM
• REQUEST TO THE PATIENT WHICH
LANGUAGE ARE YOU COMFORTABLE
• INTRODUCE YOUR SELF
• EXPLAIN YOUR ROLE
• PATIENT OBSERVATION
CHIEF COMPLAINT
• The chief complaint is the focus of the
exam
• If the patient has several complaints
e.g - blurred vision , pain , redness, etc.
• The patient decribe the problem it should
be record in him / his own words
SIGN VS SYMPTOMS
SYMPTOMS SIGN
. Swelling of the eyelids . Lid Edema
. Cyst . Chalazion
. Redness . Congestion
. Blurred vision . Refractive error(or)
cataract
History of Present illness
• Supporting data of Chief complaint
• Description of Onset
• Frequency / consistency of symptoms
• Duration of each episode
• Triggers
• Progressions
• Associated symptoms
• Treatments and duration
Common complaints
Sudden Loss of vision
• Which eye - One eye (or) Both eyes
• At what time - Morning , afternoon (or) , evening
• An injury to your eye
• You have any HTN , DM
• Eye pain
Common complaints
Double vision
• Which eye , one eye or both eyes ?
• Present if closing one eye , if so which eye ?
• Sudden or gradual?
• Horizontal or vertical ?
• Duration?
• Constant or intermittent?
• Are you diabetic?
Headache
• Duration(how long)-Time of day , AM or PM ?-
How frequent?
• Location-Eye area,brow,forehead,temples,top of
head or back of head?
• Sudden or gradual?constant or intermittent?
• Type of pain?pressure,throbbing,etc.
• Any nausea or vomiting?
• Any visual phenomenon?
• Family history of migranes?
Strabismus (Squnint)
• Duration ?sudden or gradual?
• Which eye or both?
• Constant or intermittent?
• History of surgery (date or
Dr.),patching,corrective lenses ?
• Head tilting?direction?worse when tired?
• Worse certain time of day.
• Family history of strabismus?
Past medical history
• H/O Using glasses since 10 years PGP 1
year (or) No H/O using glasses
• No H/O Ocular trauma OR not h/o injury
with stoen one eye (or) both eyes
• No H/O Rcently consultaiton OR H/O
recently consultation at locallyt they
diagnosed OU cataract they adv - who has
referred by here for further managment
contact lens history
• H/O using CL
• which type of CL
• Daily how many hours using
• which eye
Past ocular history - surgery
• S/P - LE CATARACT SX DONE ON 15-01-
2020
• S/P - BE LASIK DONE ON 25-01-2020
• S/P - RE PTERYGIUM SX DONE UNDER
LA ON 22-01-2020
Past ocular history - surgery
• S/P - BE YAG CAP DONE TA ON 01-01-
2020
• S/P - SURGICAL POST
• LA - LOCAL ANESTHESIA
• TA - TOPICAL ANESTHESIA
CRx - CURRENT MEDICATION
• Drops ? ointments ?
EXAMPLE -
BE - CIPLOX EYE DROP 4 T/D
BE - CIPLOX EYE OINTMENT 1 T/D
BE - IOTIM EYE DROP 2 T/D LAST
APPLICATION TODAY MORNING 7.00 A.M
Systemic history
• DM SINCE 5 YEARS UNDER MEDICATION
• HTN SINCE 7 YEARS UNDER MEDCAITON
• ASTHMA SINCE 1 YEARS NO MEDCAITON
• ARTHRITIS SINCE 4 YEARS
• HEART PROBLEM SINCE 1 YEAR
NOTE - IN CASE NO COMPLAITS YOU CAN
WIRTE TO THE
NO H/O HTN , DM , etc
Systemic medications
• Metaformin BID PO
• Synthroid 1OD PO
• Paxil 1 QD PO
• HCQ BD
SOCIAL AND ALLERGIES
• Smoking-medicare requirement
• Alcohol consumption-medicare
• Drugs
• Dyes(eg:Fluorescein)
• Contact lens solutions
• Seeasonal
• Describe reactions:nausea,vomitings vs
difficulty breathing and /or hives
Family history
• MEDICAL OCULAR
• HTN Cataract
• DM Glaucoma
• Thyroid ARMD
• Cancer Strabismus
• Arthritis Rheumatoid arthritis RD
General information
• Biographical information
• Tests
• MRI
• CT
• RBS
Birth history
• FULL TERM NORMAL DELIVERY
• FULL TERM CESAREAN DELIVERY
• PRE TERM NORMAL DELIVERY
• PRE TERM CESAREAN DELIVERY
• DATE OF BIRTH
Birth history
• BIRTH WEIGHT
• GESTATIONAL AGE
• HISTORY OF SEZIURES OR JAUNDICE
• HISTORY OF PHTOTHERAPY OR INCUBATOR
OR NICU FOR HOW MANY DAYS
Birth history
• MATERNAL INFECTION DURING
PREGNANCY
• HISTORY OF PARENTAL
CONSANGUINITY
• TWINS OR ONE CHILD
• DELIVERY AT HOSPITAL NAME
• NEONATAL CARE AT HOSPITAL NAME
TYPES OF TRAUMA
• LEFT EYE INJURY WITH HAND FOLLOWED
BY SUDDENLY DECREASED VISION FOR
DISTANCE AND NEAR SINCE 1 MONTH BACK
• ROAD TRANSPORT ACCIDENT (RTA) ON 17-
01-2020 EVENING 5.30 P.M FOLLLOWED BY
BLURRING OF DISTNACE VISION FOR RIGHT
EYE ONLY .
TYPES OF TRAUMA
• LOSS OF UNCONSCIOUSNESS
• INJURY WITH FEVICOL (CHEMICAL
INJURY) FOLLOWED BY SWELLING OF
THE EYE LIDS , REDNESS , WATERING
, BURNING SENSATION IN BOTH EYES
THANK YOU

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History taking in ophthalmology

  • 2. IMPORTANT OR NOT • Yes , History is important in all medical cases • Which history we are taking depends on the condition (presenting complaint) • Ocular history taking also follows same guidelines
  • 3. Importance of history taking • Obtaining an accurate history is the critical first step in determining the etiology of patient’s problem • A large percentage of the time ( around 70 % ) you will actually be able to make a diagnosis based on the history alone
  • 4. Structure of history • Introduction and describing aim & objectives • Chief complaint • History of present illness • Past medical / surgical / laser history • Systemic history • Family history
  • 5. Structure of history • Birth history • Drug history • Social history • Present medical history • Allergy history • Psychosocial Assessment
  • 6. GREETING • WISH TO THE PATIENT - GOOD MORNING SIR (OR) MADAM • REQUEST TO THE PATIENT WHICH LANGUAGE ARE YOU COMFORTABLE • INTRODUCE YOUR SELF • EXPLAIN YOUR ROLE • PATIENT OBSERVATION
  • 7. CHIEF COMPLAINT • The chief complaint is the focus of the exam • If the patient has several complaints e.g - blurred vision , pain , redness, etc. • The patient decribe the problem it should be record in him / his own words
  • 8. SIGN VS SYMPTOMS SYMPTOMS SIGN . Swelling of the eyelids . Lid Edema . Cyst . Chalazion . Redness . Congestion . Blurred vision . Refractive error(or) cataract
  • 9. History of Present illness • Supporting data of Chief complaint • Description of Onset • Frequency / consistency of symptoms • Duration of each episode • Triggers • Progressions • Associated symptoms • Treatments and duration
  • 10. Common complaints Sudden Loss of vision • Which eye - One eye (or) Both eyes • At what time - Morning , afternoon (or) , evening • An injury to your eye • You have any HTN , DM • Eye pain
  • 11. Common complaints Double vision • Which eye , one eye or both eyes ? • Present if closing one eye , if so which eye ? • Sudden or gradual? • Horizontal or vertical ? • Duration? • Constant or intermittent? • Are you diabetic?
  • 12. Headache • Duration(how long)-Time of day , AM or PM ?- How frequent? • Location-Eye area,brow,forehead,temples,top of head or back of head? • Sudden or gradual?constant or intermittent? • Type of pain?pressure,throbbing,etc. • Any nausea or vomiting? • Any visual phenomenon? • Family history of migranes?
  • 13. Strabismus (Squnint) • Duration ?sudden or gradual? • Which eye or both? • Constant or intermittent? • History of surgery (date or Dr.),patching,corrective lenses ? • Head tilting?direction?worse when tired? • Worse certain time of day. • Family history of strabismus?
  • 14. Past medical history • H/O Using glasses since 10 years PGP 1 year (or) No H/O using glasses • No H/O Ocular trauma OR not h/o injury with stoen one eye (or) both eyes • No H/O Rcently consultaiton OR H/O recently consultation at locallyt they diagnosed OU cataract they adv - who has referred by here for further managment
  • 15. contact lens history • H/O using CL • which type of CL • Daily how many hours using • which eye
  • 16. Past ocular history - surgery • S/P - LE CATARACT SX DONE ON 15-01- 2020 • S/P - BE LASIK DONE ON 25-01-2020 • S/P - RE PTERYGIUM SX DONE UNDER LA ON 22-01-2020
  • 17. Past ocular history - surgery • S/P - BE YAG CAP DONE TA ON 01-01- 2020 • S/P - SURGICAL POST • LA - LOCAL ANESTHESIA • TA - TOPICAL ANESTHESIA
  • 18. CRx - CURRENT MEDICATION • Drops ? ointments ? EXAMPLE - BE - CIPLOX EYE DROP 4 T/D BE - CIPLOX EYE OINTMENT 1 T/D BE - IOTIM EYE DROP 2 T/D LAST APPLICATION TODAY MORNING 7.00 A.M
  • 19. Systemic history • DM SINCE 5 YEARS UNDER MEDICATION • HTN SINCE 7 YEARS UNDER MEDCAITON • ASTHMA SINCE 1 YEARS NO MEDCAITON • ARTHRITIS SINCE 4 YEARS • HEART PROBLEM SINCE 1 YEAR NOTE - IN CASE NO COMPLAITS YOU CAN WIRTE TO THE NO H/O HTN , DM , etc
  • 20. Systemic medications • Metaformin BID PO • Synthroid 1OD PO • Paxil 1 QD PO • HCQ BD
  • 21. SOCIAL AND ALLERGIES • Smoking-medicare requirement • Alcohol consumption-medicare • Drugs • Dyes(eg:Fluorescein) • Contact lens solutions • Seeasonal • Describe reactions:nausea,vomitings vs difficulty breathing and /or hives
  • 22. Family history • MEDICAL OCULAR • HTN Cataract • DM Glaucoma • Thyroid ARMD • Cancer Strabismus • Arthritis Rheumatoid arthritis RD
  • 23. General information • Biographical information • Tests • MRI • CT • RBS
  • 24. Birth history • FULL TERM NORMAL DELIVERY • FULL TERM CESAREAN DELIVERY • PRE TERM NORMAL DELIVERY • PRE TERM CESAREAN DELIVERY • DATE OF BIRTH
  • 25. Birth history • BIRTH WEIGHT • GESTATIONAL AGE • HISTORY OF SEZIURES OR JAUNDICE • HISTORY OF PHTOTHERAPY OR INCUBATOR OR NICU FOR HOW MANY DAYS
  • 26. Birth history • MATERNAL INFECTION DURING PREGNANCY • HISTORY OF PARENTAL CONSANGUINITY • TWINS OR ONE CHILD • DELIVERY AT HOSPITAL NAME • NEONATAL CARE AT HOSPITAL NAME
  • 27. TYPES OF TRAUMA • LEFT EYE INJURY WITH HAND FOLLOWED BY SUDDENLY DECREASED VISION FOR DISTANCE AND NEAR SINCE 1 MONTH BACK • ROAD TRANSPORT ACCIDENT (RTA) ON 17- 01-2020 EVENING 5.30 P.M FOLLLOWED BY BLURRING OF DISTNACE VISION FOR RIGHT EYE ONLY .
  • 28. TYPES OF TRAUMA • LOSS OF UNCONSCIOUSNESS • INJURY WITH FEVICOL (CHEMICAL INJURY) FOLLOWED BY SWELLING OF THE EYE LIDS , REDNESS , WATERING , BURNING SENSATION IN BOTH EYES

Editor's Notes

  1. you can talk about duration of present complaint, associated symptoms, previous episodes etc
  2. elaborate more on ophthalmic history
  3. e