History taking in ophthalmology

HISTORY TAKING IN OPHTHALMOLOGY

1. HISTORY TAKING IN OPHTHALMOLOGY R ANUDEEP

2. IMPORTANT OR NOT Yes , History is important in all medical cases Which history we are taking depends on the condition (presenting complaint) Ocular history taking also follows same guidelines

3. I mportance of history taking Obtaining an accurate history is the critical first step in determining the etiology of patient’s problem A large percentage of the time ( around 70 % ) you will actually be able to make a diagnosis based on the history alone

4. S tructure of history Introduction and describing aim & objectives Chief complaint History of present illness Past medical / surgical / laser history Systemic history Family history

5. S tructure of history Birth history Drug history Social history Present medical history Allerg y history Psychosocial Assessment

6. GREETING WISH TO THE PATIENT - GOOD MORNING SIR (OR) MADAM REQUEST TO THE PATIENT WHICH LANGUAGE ARE YOU COMFORTABLE INTRODUCE YOUR SELF EXPLAIN YOUR ROLE PATIENT OBSERVATION

7. CHIEF COMPLAINT The chief complaint is the focus of the exam If the patient has several complaints e.g - blurred vision , pain , redness, etc. The patient decribe the problem it should be record in him / his own words

8. SIGN VS SYMPTOMS SYMPTOMS SIGN . Swelling of the eyelids . Lid Edema . Cyst . Chalazion . Redness . Congestion . Blurred vision . Refractive error(or) cataract

9. History of Present illness Supporting data of Chief complaint Description of Onset Frequency / consistency of symptoms Duration of each episode Triggers Progressions Associated symptoms Treatments and duration

10. Common complaints Sudden Loss of vision Which eye - One eye (or) Both eyes At what time - Morning , afternoon (or) , evening An injury to your eye You have any HTN , DM Eye pain

11. Common complaints Double vision Which eye , one eye or both eyes ? Present if closing one eye , if so which eye ? S udden or gradual? Horizontal or vertical ? Duration? Constant or intermittent? Are you diabetic?

12. Headache Duration(how long)-Time of day , AM or PM ?-How frequent? Location-Eye area,brow,forehead,temples,top of head or back of head? Sudden or gradual?constant or intermittent? Type of pain?pressure,throbbing,etc. Any nausea or vomiting? Any visual phenomenon? Family history of migranes?

13. Strabismus (Squnint) Duration ?sudden or gradual? Which eye or both? Constant or intermittent? History of surgery (date or Dr.),patching,corrective lenses ? Head tilting?direction?worse when tired? Worse certain time of day. Family history of strabismus ?

14. Past medical history H/O Using glasses since 10 years PGP 1 year (or) No H/O using glasses No H/O Ocular trauma OR not h/o injury with stoen one eye (or) both eyes No H/O Rcently consultaiton OR H/O recently consultation at locallyt they diagnosed OU cataract they adv - who has referred by here for further managment

15. contact lens history H/O using CL which type of CL Daily how many hours using which eye

16. Past ocular history - surgery S/P - LE CATARACT SX DONE ON 15-01-2020 S/P - BE LASIK DONE ON 25-01-2020 S/P - RE PTERYGIUM SX DONE UNDER LA ON 22-01-2020

17. Past ocular history - surgery S/P - BE YAG CAP DONE TA ON 01-01-2020 S/P - SURGICAL POST LA - LOCAL ANESTHESIA TA - TOPICAL ANESTHESIA

18. CRx - CURRENT MEDICATION Drops ? ointments ? EXAMPLE - BE - CIPLOX EYE DROP 4 T/D BE - CIPLOX EYE OINTMENT 1 T/D BE - IOTIM EYE DROP 2 T/D LAST APPLICATION TODAY MORNING 7.00 A.M

19. Systemic history DM SINCE 5 YEARS UNDER MEDICATION HTN SINCE 7 YEARS UNDER MEDCAITON ASTHMA SINCE 1 YEARS NO MEDCAITON ARTHRITIS SINCE 4 YEARS HEART PROBLEM SINCE 1 YEAR NOTE - IN CASE NO COMPLAITS YOU CAN WIRTE TO THE NO H/O HTN , DM , etc

20. Systemic medications Metaformin BID PO Synthroid 1OD PO Paxil 1 QD PO HCQ BD

21. S OCIAL AND ALLERGIES Smoking-medicare requirement Alcohol consumption-medicare Drugs Dyes(eg:Fluorescein) Contact lens solutions Seeasonal Describe reactions:nausea,vomitings vs difficulty breathing and /or hives

22. Family history MEDICAL OCULAR H TN Cataract DM Glaucoma Thyroid ARMD Cancer Strabismus Arthritis Rheumatoid arthritis RD

23. General information Biographical information Tests MRI CT RBS

24. Birth history F ULL TERM NORMAL DELIVERY FULL TERM CESAREAN DELIVERY P RE TERM NORMAL DELIVERY PRE TERM CESAREAN DELIVERY DATE OF BIRTH

25. Birth history BIRTH WEIGHT GESTATIONAL AGE HISTORY OF SEZIURES OR JAUNDICE HISTORY OF PHTOTHERAPY OR INCUBATOR OR NICU FOR HOW MANY DAYS

26. Birth history MATERNAL INFECTION DURING PREGNANCY HISTORY OF PARENTAL CONSANGU INITY TWINS OR ONE CHILD DELIVERY AT HOSPITAL NAME NEONATAL CARE AT HOSPITAL NAME

27. T YPES OF TRAUMA LEFT EYE INJURY WITH HAND FOLLOWED BY SUDDENLY DECREASED VISION FOR DISTANCE AND NEAR SINCE 1 MONTH BACK ROAD TRANSPORT ACCIDENT (RTA) ON 17-01-2020 EVENING 5.30 P.M FOLLLOWED BY BLURRING OF DISTNACE VISION FOR RIGHT EYE ONLY .

28. T YPES OF TRAUMA LOSS OF UNCONSCIOUSNESS INJURY WITH FEVICOL (CHEMICAL INJURY) FOLLOWED BY SWELLING OF THE EYE LIDS , REDNESS , WATERING , BURNING SENSATION IN BOTH EYES

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