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Patient profile and case History


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Patient profile and case History

  1. 1. PATIENT PROFILE & CASE HISTORY Manish Khanna B.Optom 13th October, 2012
  2. 2. Patient Profile Name of patient Address Contact details Age Occupation Race / ethnicity Gender Hobbies / lifestyle Education level
  3. 3. 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
  4. 4. 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
  5. 5. 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?”
  6. 6. 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?”
  7. 7. 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
  8. 8. 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
  9. 9. 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.
  10. 10. Possible Chief ComplaintsCould Include Decreased vision Headache Eyestrain / asthenopia Itching Burning / stinging eyes Tearing Foreign body sensation Double vision (diplopia) Flashes Floaters
  11. 11. 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
  12. 12. 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
  13. 13. Medications and Allergies Drug Name Purpose Dosage Compliance Side effects Duration of the treatment Cause of allergy: Environmental or medication
  14. 14. 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.
  15. 15. 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
  16. 16. 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