The document provides guidance on taking an effective ophthalmic patient history. It emphasizes the importance of obtaining an accurate history, which can often provide a diagnosis. The history should include introducing oneself, chief complaint, history of present illness, past medical history, drug history, family history, and social history. Key details and tips are provided on questioning patients and documenting each component of the history.

1. OPHTHALMIC
HISTORY TAKING
JAYENDRA JHA
OPTOMETRIST
C. L. GUPTA EYE INSTITUTE
MORADABAD

2. Session Structure
• Introduction and Describing Aim &Objectives
• Chief complaint
• History of present illness
• Past medical history
• Systemic enquiry
• Family history
• Drug history
• Social history

3. Importance of History Taking
• Obtaining an accurate history is the critical first step in determining
the etiology of a patient's problem.
• A large percentage of the time ) 70%), you will actually be able
make a diagnosis based on the history alone.

4. How to take a history?
• The sense of what constitutes important data will grow exponentially
in future as you learn about the pathophysiology of disease.
• You are already in possession of the tools that will enable you to
obtain a good history.
• An ability to listen &ask common-sense questions that help define
the nature of a particular problem.
• A vast & sophisticated fund of knowledge not needed to successfully
interview a patient.

5. Introduce yourself.
• Note – never forget patient names
• Create patient appropriately in a friendly relaxed way.
•Confidentiality and respect patient privacy.
General Approach
Try to see things from patient point of view. Understand
patient underneath mental status, anxiety, irritation or
depression.
Always exhibit neutral position.
Listening
Questioning: simple/clear/avoid medical terms/open, leading,
interrupting, direct questions and summarizing.

6. .
Taking the history & Recording:
• Always record personal details: NASEOMADR.
– Name,
– Age,
– Address,
– Sex,
– Ethnicity
– Occupation,
– Religion,
– Marital status.
– Date of examination

7. Complete History Taking
• Chief complaint
• History of present illness
• Past medical /surgical history
• Systemic review
• Family history
• Drug Allergy history
• Social history
• Present medical history.

8. CHIEF COMPLAINT

9. Chief Complaint
• The main reason push the pt. to seek for visiting a ophthalmic
consultation.
• Usually a single symptoms, occasionally more than one complaints
e.g. blurred vision, swelling, pain, trauma, inflammation etc.
• The patient describe the problem in their own words.
• It should be recorded in his/her own words.
• What brings your here? How can I help you? What seems to be the
problem?

10. Chief Complaint
Chief Complaint (CC):
• Short/specific in one clear sentence communicating present/major
problem/issue.
• Timing
• Recurrent
• Any major disease important e.g. DM, asthma, HT, pregnancy.
• Note: CC should be put in patient language.

11. Duration: tips
• Exact duration.
• For how long you are suffering.
• When you were completely normal.
• Is this complain for the first time or you have other episodes.

12. History of Present Illness
Details & progression, regression of the CC:

13. History of Present Illness - Tips
• Elaborate on the chief complaint in detail
• Ask relevant associated symptoms
• Have differential diagnosis in mind
• Lead the conversation & thoughts
• Decide & weight the importance of minor complaints

14. Sequential presentation
•Always relay story in days before admission e.g. 1 week
before the admission, the patient fell while gardening&
causes ocular trauma
•Narrate in details – By that evening, the eye became swollen
and patient was unable to see. Next day patient attended
hospital and they gave him some oral and topical antibiotics.
He doesn’t know the name. There is no effect on his
condition and two days prior to admission, the eye continued
to swell and started to discharge ands pain.
History of Presenting Complaint (HPC)
In details of present problem with- time of onset/ mode of
evolution/ any investigation, treatment & outcome/any
associated +’ve or -’ve symptoms.

15. History of Presenting Complaint (HPC)
In details of symptomatic presentation
•If patient has more than one symptoms, like pain, foreign body
sensation and discharge, take each symptom individually and follow
it through fully mentioning significant negatives as well.

16. History of Present Illness - Tips
• Avoid medical terminology & make use of a descriptive language that
is familiar to them
• Ask OPQRSTA for each symptoms

17. Pain OPQRST
Position/site
Severity – how it affects daily work/physical activities. Wakes
him up at night, cannot sleep/do any work.
Relationship to anything or other bodily function/position.
Radiation: where moved to
Relieving or aggravating factors – any activities or position
Quality, nature, character – burning sharp, stabbing, crushing; also
explain depth of pain – superficial or deep.
Timing – mode of onset (abrupt or gradual), progression
(continuous or intermittent – if intermittent ask frequency/
nature.)
Treatment received or/and outcome.
Onset of disease
Are there any associated symptoms? .

18. Past Medical Illness

19. Past Medical /Surgical History
• Start by asking the patient if they have any medical problems
• IHD/Heart Attack/DM/Asthma/HT/RHD, TB/Jaundice/Fits :E.g. if
diabetic- mention time of diagnosis/current medication/clinic check
up
• Past surgical/operation history
• E.g. time/place/ what type of operation.
• Note any blood transfusion / blood grouping.
• H/O dental extractions/circumcision & any exessive bleeding during
these procedures.
• History of trauma/accidents
• E.g. time/place/ and what type of accident
• Any minor operations or procedures including endoscopies, dental
interventions, bipsies.

20. Drug History

21. Drug History
• Drug History (DH)
• Always use generic name or put trade name in brackets with dosage,
timing &how long.
• Example: Ranitidine 150 mg BD PO
• Note: do not forget to mention: OCT/Vitamins/Traditional /Herbal
medicine & alternative medicine as cupping or cattery or
acupuncture.
• Blood transfusion.

22. Drug History
• Bd (Bis die) - Twice daily (usually morning and night)
• Tds (ter die sumendus)/Tid (ter in die) = Three times a day mainly 8
hourly
• Qds (quarter die sumendus)/Qid (quarter in die) = four times daily
mainly 6 hourly
• Mane/(om – omni mane) = morning
• Nocte/(on – omni nocte) = night
• Ac (ante cibum) = before food
• Pc (post cibum) = after food
• Po (per orum/os) = by mouth
• Stat – statim = immediately as initial dose
• Rx (recipe) = treat with

23. Family History

24. Family History
• Any familial disease/running in families e.g. breast cancer, IHD, DM,
schizophrenia, Developmental delay, asthma, albinism.
• Infections running in families as TB, Leprosy.
• Cholera, typhoid in case of epidemics.

25. Social History
• Smoking history - amount, duration & type.
• A strong risk factor for IHD
• Alcohol history - amount, duration & type.
• Occupation, social & education background, ADL, family social
support& financial situation.
• Social class.
• Home conditions as:
• Water supply.
• Sanitation status in his home & surrounding.
• Animals / birds in his/her house.

26. Social History

27. Social History: Smoking
• The most important cause of preventable diseases.
• Smoking history - amount, duration & type.
• Amount: pack”year calculations.
• Duration: continuous or interrupted.
• Any trials of quitting & how many.
• Deep inhalation or superficial.
• Active or passive smoker.
• Type: packs, self-made, Cigars, Shesha , chewing etc.

28. Social History: Smoking
• Ask the smoker whether he is willing to quit or not.
• Do not forget to encourage the smoker to quit whenever contacting
a smoker as it is proved to increase quitting rate.
• If he is willing to quit, but can not, help him by NRT, buberpion.

29. Social History: Alcohol.
• Whether drinking alcohol or not.
• If drinking know whether it is healthy or not.
• Healthy alcohol use:
• Men: 14 units/week, not > 4 units/session.
• Women: 7 units/week, not > 2 units/session.
• Don’t forget that healthy alcohol use is associated with less IHD &
Ischemic CVA.
• Unhealthy alcohol use is associated with cardiomyopathy, CVA,
Myopathies, liver cirrhosis & CPNS dysfunction.

30. Social History: Alcohol.
• Note:
Do not advice patients or individuals , to drink for health, because of:
• Religious & cultural reasons.
• Possibility of addiction with its known health problems.

31. Other Relevant HistoryOther Relevant History
• Immunization if small child
• Note: Look for the child health card.
• Travel / sexual history if suspected STDs or infectious disease
• Note:
• If small child, obtain the history from the care giver. Make sure; talk
to right care giver.
• If some one does not talk to your language, get an
interpreter(neutral not family friend or member also familiar with
both language). Ask simple & straight question but do not go for yes
or no answer.

32. System Review
General
•Weakness
•Fatigue
•Anorexia
•Change of weight
•Fever/chills
•Lumps
•Night sweats

33. SOAP
Subjective: how patient feels/thinks about him. How does he look.
Includes PC and general appearance/condition of patient
Objective relevant points of patient complaints/vital sings, physical
examination/daily weight, fluid balance, diet/laboratory investigation
and interpretation
Plan: about management, treatment, further investigation, follow up
and rehabilitation
Assessment: address each active problem after making a problem
list. Make differential diagnosis.