History taking in optometry

optometry

1. History taking in optometry Presented by – Prarthana Buragohain

2. A good history commonly leads to a diagnosis Helps you focus on examination Indicates when/what investigation are needed Helps determine the functional impact of the condition

3. General out patient department history taking procedure Demographic data- Name (for identification , filing system, friendly) Age (age related disease eg - children- congenital,old -senile disease) Gender (gender related disease) Address (endemic disease, social status ) Occupation (occupation related disease)

4. Chief complain (c/o) In patient’s language ( in which over confortable language he/she want to speak) Duration of complaint If it is involving one or both eyes? Any associated symptoms? Any similar problem before? Previous medical advice and medication PTO.

5. There are two types of complain:- 1. Visual complaints:- Sudden loss of vision, diminuation of vision , blurring of vision , photophobia. 2. Non visual complaint:- Discharge , pain , itching , swelling

6. Spectacle history Is he/she using any spectacle If using since how many Days/months/years he/she using the spectacle Also check out present glass prescription by neutralisation of lens ( by manually or automated eg-lensometer ) glass history should must be taken if he/she is complaining of blurring of vision or diminishing of vision.

7. Ocular history We should ask the patient if similar ocular related problem have existed before Previous eye surgery or eye injury Chronological order of major illness and major problem Ask the use of ocular medication if he/she is presently using.

8. Systemic history We should ask the patient about any systemic health related history is existing or not Eg - diabeties – if patient have diabeties and it may lead to diabetic retinopathy ( which indicate blurring of vision and related to thickening of the retina with 500 micron) Hypertension Thyroid Asthama Heart disease Malingant diseases

9. Contact lens history If patient using contact lens history we have to note it up with asking of which company contact lens you are using

10. Systemic medication history Of what type medicine you are using to cure the systemic disease

11. Drug allergy disease history We should ask the patient about you have any allergy to the drugs

12. Family history We should ask the patient whether his mother, father , grandfather, grandmother have these disease Glaucoma Squint Myopia Cataract Poor vision You should also ask about your family systemic history

13. Birth history Birth history is taken for children only The history should be proceeds as if baby birth is premature or forcep delivery or low birth weight.

14. Social history We should ask if patient is consuming Smoking Alcohol Or any occupation or home circumstances problem

15. All these are ask to each patient to each ocular department. Certain complaint of ocular cases are follows

16. Catract out patient dept history taking procedure- senile cataract case Demographic data – it is seen in old patient usually above the age of 45 years Presenting complain- 1. gradual loss of vision 2. May be associated with coloured halos , glare History of present illness h/o of radiation, injury to affected eye, diabetic mellitus,steroid intake, To rule out diseases affecting surgical treatment eg diabeties mellitus , hypertension.

17. Uvea out patient h/o taking procedure – acute iridocyclitis Demographic data Presenting symptoms- moderate to servere pain , photophobia, watering,redness,diminution of vision in sudden onset. h/o of present illness- h/o of allergic condition like brochial asthama , hay fever, allergic skin condition h/o of joint pain to rule out rheumatoid disease

18. h/o of trauma to eye h/o of sinusitis Past history h/o of similar attacks in past h/o of systemic infection eg tubercolosis,leprosy,syphills etc h/o of non infectious disease eg collagen disorder, gout etc h/o of allergic and autiimmune disorder

19. Cornea out patient procedure history taking – corneal opacity and pterygium Corneal opacity- Demographic data Presenting symptoms- whitish scar, causing defective vision History- history of trauma to eye Pterygium:- Demographic data Age and sex- more common in male than female occur in middle age Presenting symptoms PTO.

20. Extra growth on the cornea Slight irritation or foreign body sensation Diminuation of vision due to astigmatism procced by traction on the cornea Diplopia may occur due to limitation of ocular movement

21. Glaucoma out patient dept history taking procedure- primary open angle glaucoma Demographic data- usually affects 1 to 100 of general population above the age of 40 age . The disease is usually bilateral. presenting symptoms –1. mild headache 2. Difficulty in reading 3. Occasionally patient notice a defect in visual field( scotoma ) 4. In late stages patient complain of delayed dark adaptation Family history is also taken

22. Strabismology out patient dept history taking procedure Demographic data Presenting symptoms-patients presents with deviation of one eye h/o of present illness- Age of onset Mode of onset , sudden or gradual Precipitating factor such as systemic illness, trauma, h/o of diplopia Birth history is important in early childhood onset deviation and h/o of glasses Family history is important in case of stabismus

23. Case assesment from uvea out patient department Mr no- 1283965 Name- Vdaya chndrika Age -51 years sex- female History- nil Systemic disease – nil Complaint- c/o recurrent redness since 15 days in right eye c/o eye pain with pricking sensation since 15 days h/o using glasses from 2 months

24. Acceptance OD- +0.75DSph/-1.00Dcyl*75 6/9 OS- plano / 6/6 add= +2.00Dsph Vision Distance Near OD OS OD OS UNAIDED 6/18 6/6 PINHOLE 6/9 BEST CORRECT 6/9 6/6 6/6RS 6/6RS

25. OLD GLASSES:- OD- +2.00DSph OS- +2.00Dsph slit lamp examination OD OS Lid normal normal Conjunctiva congetion congetion more inferior more inferior

26. Cornea inferior stroma inferior stroma edema with deep with deep vessels vessels Anterior 1+cells cell 0.5 Chamber iris posterior posterior synechia synechia Pupil p.s at 4o clock posterior synechia inferior

27. Fundus CD 0.3 , CD 0.3’ HDRR , FR+, HDRR, FR+ Rest nornal Rest normal vitreous cells + inferior snow ball

28. THANK YOU