Ahmad Abid bin Abas 07-5-2Ahmad Asyraf bin Mohamed 07-5-3
Preparation Brief Introduction of yourself to patient Confidentiality Documentation Communication
Personal Data : - Name (for identification, filing system, friendly) - Age (age related diseases-child : congenital diseases, old : senile diseases) -Sex (sex related diseases) -Address (endemic diseases, social status) -Occupation (occupation related diseases, visual needs)
Chief Complain (c/o) : - in Arabic/Malay , in patient’s words -don’t forget duration of c/o -don’t use diagnostic words. -return and correct unrelated complaints -if more than one, arrange by chronological and by importance.
Type of complaints : 1) Visual complaints : -(sudden loss of vision, diminution of vision, blurring, photophobia etc..) 2) Non-Visual complaints : -(discharge, pain, itching, swelling etc..)
1) Describe each complaints in scientific words2) Analyse each complaints as regards; ◦ Onset ◦ Course ◦ Side ◦ Duration ◦ Associated symptoms ◦ Previous medical advice and medication
1) Ask if similar or related problems haveexisted before.-Chronological order the major illness andmajor operations- previous eye surgery2) Past use of medications.3) History of previous glasses.4) Diabetes Mellitus and Hypertension5) Systemic Illness
Ask if any other member of the family havesimilar condition or other eye related diseases.