1. History taking for an ophthalmic patient requires a systematic guide with a good sequential questions in order to reach a peak point of patient's ocular problem management 2. ocular patient's history should be documented down on patient's own word not speciality words which are diagnostic before a diagnosis 3. with good communication skills a clinicial will explore a lot of information which will help for further investigations

1. OPHTHALMIC PATIENT HISTORY TAKING
CLINICAL OPTOMETRY
NTA LEVEL 5
KILIMANJARO COHAS
MWAKYOMA BSc. Optometry

2. Objective
• At the end of this session a student should be able to:
i. Define history taking
ii. List goals of taking history
iii. Describe components of history
iv. Record history

3. Task 1 :Brain storming 2 minutes
• What did you understand about history taking?

4. Introduction
• Patient history taking is a phenomenon of exploiting and
documenting important information's about patient’s illness
• This is a purely subjective procedure which requires carefully and
systematic questioning
• With good communication skills it is easy to have a good destination

5. Goals of the history
i. Identify the patient
ii. Identify other practitioners who have cared for the patient or who
may care for the patient in the future
iii. Obtain a diagnosis
iv. Select therapy
v. Consider socioeconomic and medicolegal factors

6. Components of the history (1)
• Chief complain
• Present illness
• Past ocular history
• Ocular medications
• General medical and surgical history

7. Components of the history (2)
• Systemic medications
• Allergies
• Social history
• Family history

8. Chief complain (1)
• This is main reason for a client to visit at a clinic
• It should be written on a patient’s own words and NOT technical
words on paraphrasing patient’s explanation for example: redness,
burning, light flashes
• Technical terms suggest premature diagnosis which is prohibited on
this section for example: photophobia, conjunctivitis, photopsia

9. Brain storming 1 minute
• What are disturbances of vision which can be reported from a
patient?

10. Chief complain (2)
• Examples of questions
i. What are the main problems that you are having with your eyes?
ii. Why did you come here?

11. Present illness (1)
• This component always describe a chief complain in details
• It is usually eliciting a preliminary diagnosis

12. Present illness (2)
• Consist of the following
a. Time and manner of onset ( was it sudden or gradual?)
b. Severity (has the problem improved, worsened or remained the
same?)
c. Influences
d. Constancy and temporal variation (has the problem been
intermittent or seasonal, or does it worsen at a particular time of
day?

13. Present illness (3)
e. Laterality ( is the problem unilateral or bilateral?)
f. Duration (how long you have this condition?)

14. Past ocular history (1)
• Involves patient’s previous eye trouble
• Questions for eliciting information are dedicated on:
i. Use of eyeglasses
ii. Use of ocular drugs

15. Past ocular history (2)
iii. Ocular surgery
iv. Ocular trauma
v. Hx of amblyopia in childhood
• any answer of yes will bring on why, how, where, when and by whom

16. Ocular medication(1)
• Involves prior and present use of ocular medications
• Involves name, dosage, frequency and duration which will help for
management planning
• Sometimes a patient did not know their drugs, on this case as
clinician should know/learn general classes of medication

17. Buzzing 3 minutes
• Give out two reason for taking ocular medication history

18. Ocular medication(2)
• Essential reasons for taking ocular medication hx
i. To know how patient respond to prior therapy
ii. Recent therapy (within six month) can affect present patient’s
status

19. Ocular medication(3)
• Eye drop container’s Cup color and their possible drugs
color Drug
Green Pilocarpine, carbachol, phospholine iodide
Red Atropine, homatropine, cyclopentolate, tropicamide,
phenephrine
yellow Timolol 0.5%, levobunolol 0.5%, metipranolol
Blue Timolol 0.25%, levobunolol 0.25%

20. General medical and surgical history(1)
• Involve present and past general medical history
• Many ocular diseases are associated with systemic conditions
• General medical status should be known for proper evaluation
• In pediatric birth history and mother medication are important

21. General medical and surgical history(2)
Questions to ask
a. What has the blood pressure been in the past?
b. Is there any evidence of diabetes?
c. Is there any history of cardiac disease?

22. Systemic medications
• Systemic drugs which are taken recent or present should be
documented
• This is because of some drugs can have ocular toxic such as systemic
steroids, hydroxychloroquine
• Others tends to induce refractive errors

23. Allergies
• Other patient has experienced an allergies after using some drugs
• Allergen reactions are such as itching, rashes, stomach upset
• Drugs which have sulfur contents reported to cause reactions such as
diamox
• Other patients reports sodium cromoglycate causes nausea
• Clinician after having previous medication hx has to ask if he has any
reaction on the previous one

24. Family history
• To know and document family hx is important as ocular non infective
disorder are genetically transmitted from one generation to another
• Clinician can ask a question such as “ Are there any eye problems,
other than just reading glasses in your family background”

25. Key points
• Patient history is documented in patient’s spoken words not medical
terminologies
• Clear history is taken from sequential order of questions

26. Evaluation
i. List components of ocular patients history
ii. List goals of taking history

27. References
• Joshua, Z. Diagnostic examination of the eye. Second edition. United
States of America: J.B. Lippincott Company
• Wilson FM, Blomquist PH. Practical ophthalmology. Sixth edition.
United States of America: Kinetic publishing service