Principles of ophthalmic history taking.pptx

This presentation on ophthalmic case history taking enlightens since from its origin to the present advance status of developments in ophthalmology

1. An investigation into the genesis of principles of ophthalmic history taking Authors Dr S K Prabhakar Dr Harmanpreet Kaur Dr T anish Garg 1. Interrogation of the patient 2. Physical examination of the patient

2. Context: History taking deals with the association of symptomatology described by the patient and the physical findings discovered by the physicist or the surgeon accordingly. Hence in this study an attempt was made to find the origin, development, expansion and improvisation of history seeking in the recent past years. Aims and objectives: T he main purpose was to find the usefulness and benefit of history taking for both the patient and the doctor. Secondary aim was to find out how the symptoms were correlated in the history itself concerning a specific disease entity. Methods and materials: A thorough search was conducted to find the manuscripts describing the patients symptoms and signs from the inception of Egyptian eye of Horus, uttara tantra of Sushruta samhita, Hutchison's and Macleod's clinical examination manuals in the internet archives in addition to PubMed database. Results: The Egyptian description provided a very early evidence of inception of ophthalmic history and treatment. Sushruta discussed a total of 76 eye disorders and their manifestations including the surgical treatment for 26 eye affections. In the recent past years, Hutchison wrote on the method of history taking and a elaborative expedition was visible in the Macleod's clinical manuscripts. It appeared that the subject of history taking is minimal or nil in Thomas young's philosophical transaction on the physiology of vision in accommodation, Von Hermann Helmholtz treatise on color vision expedition, Fuchs text book of ophthalmology and sir Stewarts Duke Elders 15 volumes of system of ophthalmology. PubMed search revealed a large magnitude of case reports that enlighten the symptomology correlating the clinical diagnosis. Conclusion: Effective and powerful history taking is primarily a beneficial advantage for making a provisional diagnosis and treatment of a disorder, leading to develop a rapport with the patient for a life long provision of medical services. The symptoms were correlated with the diagnosis, plausibly extracting most of the information extensively from case studies available in the medical literature.

3. Keywords : Eye of Horus, Sushruta samhita (Volume III Uttara-Tantra), Hutchison's (13 th edition) and MacLeod's clinical examination (9 th edition) References : 1 . Sushruta samhita, volume III uttara tantra english translation by professor Kaviraj 2. Hutchison clinical methods, 13 th edition 3. MacLeod’s clinical examination, 9 th edition 4. Takusewanya M. How to take a complete eye history. Community Eye Health. 2019;32(107):44-45. 5. Wang MY, Asanad S, Asanad K, Karanjia R, Sadun AA. Value of medical history in ophthalmology: A study of diagnostic accuracy. J Curr Ophthalmol. 2018 Sep 27;30(4):359-364. 6. Howcroft MJ. Ocular history and examination techniques. Prim Care. 1982 Dec;9(4):647-59. 7. Jackson CL, Rivers RJ, Conti ME, Freedman LS, Song M, Lehmann JD, Pandian V. The Value of History and Physical Examination to Optimize Outcomes of Cataract Surgery: A Systematic Review. AANA J. 2023 Dec;91(6):449-454.

4. Principles of history-taking Put the patient as ease by calling the patient by name with due respect and courtesy not forgetting patient’s name Choose an appropriate setting consisting of provision of similar sitting chairs for both doctor and patient. The examiner sits on the desk side avoiding conversation across the table that may precipitate emotional reaction. Start by eliciting the presenting history regarding age and work place . Encourage the patient to start an uninterrupted story regarding a purpose of arrival to the hospital. Use selective questions to clarify the presenting history further by asking associated symptoms at the same time avoiding repetition of the symptoms.

5. Use further questions of diagnostic relevance for example symptoms of macular disorders such as metamorphopsia, micropsia and macropsia. Ask cardinal questions while reviewing the systems for the association of comorbidity. Use language the patient understands preferably in a colloquial local language. Avoid suggesting symptoms or answers to the patient not to mislead the history. Write notes while the patient talking (but silently ) however it is wise to listen in serious conditions. History from other informants such as relatives and friends provides reliable information especially children.

6. Problem patient Garrulous patient needs great attention for managing anxiety and guilty feeling. Uncommunicative patient is usually adamant in nature not willing for hospital visits and treatment needs special care and compassion. Tearful patient may necessitate use of handkerchiefs hence a box containing paper hankies are provided with appropriate counselling especially with regard to situations of grief. Angry patient should be managed with utmost care and calmness as seen with patients referred from other centres and especially patients with long waiting periods. Handling sensitive situations such as history of HIV and syphilis should be handled with utmost sympathy. Special role of a student is disadvantaged as they are benefitted from the patient however a consent is sought most of the times for easy history taking. Psychiatric histories and The mental state examination of the patient can not be over emphasized.

7. Putting principles into practice Patients demography Presenting history Age provides an intrusion into the presence of various ocular and systemic disorders at all age groups. In children Presence of white reflex in the pupillary area suggesting congenital cataract, pseudoglioma, retinoblastoma, PHPV and parasitic endophthalmitis. History of blurred vision, deviation of the eye and abnormal head posture suggesting a possible diagnosis of strabismus. History of persistent excessive lacrimation is suggestive of congenital or acquired lower lacrimal excretory system obstruction. History of night blindness may suggest vitamin A deficiency, retinitis pigmentosa and other tapeto-retinal disorders such as Oguchi disease and congenital stationary blindness. History of eyelid drooping and protrusion with large globes may suggest congenital ptosis and primary congenital glaucoma. Progressive deterioration of the vision with whitening of the front portion of the eye may suggest corneal dystrophy in children and adults as well.

8. Under performance in schools in children suggest a possibility of presence of refractive errors. In adults P resence of colored halos in adults may suggest a diagnosis of cataract and glaucoma. Experiencing diplopia in adults may be suggestive of ocular motility disorders. P ainful loss of vision may imply a possible diagnosis of acute congestive glaucoma, corneal ulcer, acute anterior uveitis, panophthalmitis and endophthalmitis and optic neuritis apart from trauma. Gradual loss of vision may suggest senile cataract, chronic simple glaucoma, corneal dystrophies, diabetic retinopathy, age related macular degeneration, senile optic atrophy and apart from traumatic and neurological causes. Various retinal manifestations correlated with history regarding systemic diseases such as endocrine, metabolic and renal disorders

9. History of presenting illness This section essentially consists of elaborating the nature of presenting complaints starting from the duration of the symptoms onset, whether gradual or sudden, aggravating and relieving factors, associated relevant symptoms, how actually the symptom started, and time of the day. For example Ocular pain of acute iridocyclitis aggravates during sleep and relieves on awakening. Obstructive epiphora aggravates on exposing to wind or fan especially on a moving vehicle. The onset of migraines headache is heralded by the appearance of scintillating scotoma and fortification spectrum associated with emesis. The vision of nuclear cataract improves during evening time due to pupillary dilatation in contrast to cortical cataract Pain of optic neuritis exaggerating on eyeball movements Worsening of ptosis as the day progresses as seen in myasthenia gravis Sudden onset of floaters or increase in number as seen in retinal detachment History of joint pain associated with recurrent redness, dryness and pain in eyes

10. Past history H istory of diabetes mellitus and hypertension, previous ocular surgery, spectacle usage, trauma, tuberculosis, leprosy ,HIV, syphilis Systemic history Patient diagnosed to have collagen vascular disease hemodialysis, renal transplantation , cardiac bypass surgery, pacemaker implantation, cardiovascular accident Drug history H istory of HCQ intake risking central vision History of anticoagulant risking ophthalmic surgical procedure History of long term use of topical steroids posing susceptibility for cataract and glaucoma History of anti tubercular agents causing possible optic nerve dysfunction

11. Macleod's clinical examination 9 th edition

12. The Eye Of Horus: A Timeless Symbol Of Healing And Renewal

13. Sanskrit Samhita Siddhant-KDMG’s Ayurved medical college & hospital

14. Ancient Hindu text of Sushruta samhita shastra and Kartarika with surgical instruments

15. Take away key points History is important for two reasons: In most instances it provides a clear indicative of the problem; It also forms the foundation of a satisfactory doctor-patient relationship. It is essential to use a flexible method of history-taking. The patient should be encouraged to give an account of the presenting history without interruption The supplementary questions are of two kinds those required to fill in the gaps of the patients account and specific questions designed to clarify the diagnostic alternatives.

16. Terms used by the patient or clinician should be understood by both the parties. Information volunteered by the patient is more valuable than obtained by questioning. Ope n ended question are preferable to leading questions. A supplementary accoun t from a third party is often of great value. Conclusion: Effective and powerful history taking is primarily a beneficial advantage for making a provisional diagnosis and treatment of a disorder, leading to develop a rapport with the patient for a life long provision of medical services. The symptoms were correlated with the diagnosis, plausibly extracting most of the information extensively from case studies available in the medical literature. Problem patients require special consideration and compassion.,

17. Thank you