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
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