Ophthalmology

Ocular History

INTRODUCTION The history should be “HIS STORY” and not what the physician

wants to hear. How to begin:

o Welcome the patiento Introduce yourselfo Ensure comfort and privacy

Signs vs Symptoms :o Signs : what you observe; objectiveo Symptoms : what patient relays; subjective

OCULAR HISTORY Present Complaint History of Present Illness Review of Systems Past Medical History Medications Allergies Family History Social History

CHIEF COMPAINT Reason why the patient came in

o be concise, avoid details Taken from the patient him/herself or from relatives/guardians

HISTORY OF PRESENT ILLNESS Get more details from the chief complaint Use open-ended questions Establish good flow of information Quantify and Qualify (QQ)

8 Elements of HPI1. Location – left or right eye, front or back of the eye2. Quality – burning pain, heaviness (glaucoma)3. Severity – glaucoma accompanied by nausea and vomiting4. Duration – how long has the problem been occurring5. Timing – when the patient perceives the problem; every morning,

every other day, etc6. Context – conditions in which the problems arise7. Modifying factors8. Associated signs and symptoms

Start with general questions, and then get more specific Do not ask more than one question at a time, like “Are your eyes

irritated and have discharge?” Give the patient time to answer the question Politely guide him/her back to the subject if he/she goes off on a

tangent Do not record everything the patient says in the history

Think of COLDER Character – quality, severity, context, associated signs and

symptoms Onset – Timing Location Duration Exacerbation – Modifying factors Reliefs – Modifying factors

REVIEW OF SYSTEMS Relates to the condition of the body

o Blurring of vision associated with high cholesterolo Think of this as a review of symptomso Most complete ROS involves asking symptoms-related

questions. Ex: In cataract patient “Is your blood sugar elevated?”

PAST MEDICAL HISTORY Past Ocular History (e.g trauma, itchiness) Past Systemic Medical History Past Surgical History

o Indicate which eye, what kind of surgery, when the surgery happened, the institution, name of the doctor, if possible

MEDICATIONS List of current medications Dosage Frequency

o There are medications that are contraindicated or contain side effects

o Use of steroids like in chronic asthma – develop cataract or glaucoma

o Drugs containing phenylamine are contraindicated to patients with glaucoma because it exacerbates the condition by increasing intraocular pressure

Allergieso Drug allergieso Asthma (some drugs are contraindicated like drugs which

exacerbate asthma)

FAMILY HISTORY Glaucoma Retinal detachment Diabetes Hypertension Myopia

SOCIAL HISTORY Tobacco consumption

o usually leads to dry eyes and early cataract formation Alcohol use Recreational drugs Occupation Hobbies

o Nature of work of patient (occupation hazards) should be considered in prescribing eyeglasses

o E.g. using computer or watching TV would dry the eyes, so, call center agents usually have dry eyes and foreign body sensation

CONFIDENTIALITY Remembering confidentiality is the most important part of the

history.

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SAMPLE CONVERSATIONIntern: Good morning Mrs. Cruz! I am Jose Mercado , your intern. We are going to talk about your problem. What brings you to the ER today?(chief complaint/general question)

Patient: Why? I have known Alberto for years. I was his high school teacher, you know. (going off topic)

I: Wow! That’s interesting Mrs. Cruz! You don’t look old enough to be his teacher. Are you having problem with your vision? (getting back to the subject)

Px: I can’t see!

I: Are you having trouble with one or both eyes? (location)

Px: Just my left eye. I can’t read the newspaper and the faces on TV are distorted.

I: When did you first notice the problem?(onset)

Px: Last Friday I noticed I couldn’t with my left eye.

I: What were you doing when that happened?(context)

Px: I was looking out my front window at the person selling vegetables across the street.

I: Did you lose your vision suddenly or gradually? (duration)

Px: I closed my right eye and realized I couldn’t see.

I: Has your vision changed for better or worse since then? (timing)

Px: No, it’s just bad all the time.

I: How much or what part of your vision seems to be affected?(quality, location)

Px: It’s just my straight ahead vision.I can see all around it.

I: Is your vision completely blacked out, or can you see objects in the area affected? (severity – central, peripheral vision or total blindness, color)

Px: I can see things, but they look distorted.

I: Do you have any other visual symptoms? (associated signs and symptoms)

Px: No.

I: Have you done anything to treat the problem? (modifying factors likeusingeyedrops)

Px: I went to see another eye doctor who told me I have some kind of degeneration, and he told me to come here.

Note: The questions that you ask don’t always fit neatly into one of the element categories. The elements are guidelines, and all elements won’t necessarily be needed in all histories.

SRS QUESTIONS1. 2. Percentage of doctors that interrupt the patient after the

first question is?a. 60 %b. 57 %c. 22 %

3. Number of seconds until doctors interrupt patients before they complete their opening statement

a. 60b. 57c. 30d. 18

4. Percentage of patients who went back on to complete their statement is?

a. 80%b. 43%c. 17%d. 2%

5. The chief complaint was blurring of vision on the RE (OD). The history of a 66y/o non-diabetic non-hypertensive patient complaining of gradual painless blurring of vision which is worsen by exposure to sunlight, but have better vision at night. The key word that meant it is a non-emergency in nature is?

a. gradual painlessb. worsen by sunlightc. blurring of visiond. better night vision

6. The patient walks in with complaint of being hit/splash by the battery solution coming from the truck battery that exploded.

a. get a good historyb. perform a proper PEc. instill anestheticd. call the ER residente. irrigate immediately

7. The jolly overweight lady whose chief complaint is double vision, you must ask for:

a. social historyb. past medical historyc. medicationsd. family historye. all of the above

8. Which is more dangerous?a. allergic reactionb. adverse reaction

answers: B, D, D, A, D, E, A

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