Case History Walter Huang, OD Yuanpei University Department of Optometry.
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Transcript of Case History Walter Huang, OD Yuanpei University Department of Optometry.
Case HistoryCase History
Walter Huang, ODWalter Huang, OD
Yuanpei UniversityYuanpei University
Department of OptometryDepartment of Optometry
Case HistoryCase History
The goal of case history is to obtain an The goal of case history is to obtain an understanding of the patient’s problems understanding of the patient’s problems and needsand needsIt consists of a series of questions to learn It consists of a series of questions to learn about the patient, the purpose for the visit, about the patient, the purpose for the visit, and the patient’s ocular health history and and the patient’s ocular health history and general health historygeneral health history
Case HistoryCase History
Case history is the Case history is the most important most important part of part of the exam because it guides the exam by the exam because it guides the exam by helping to narrow down the list of tests that helping to narrow down the list of tests that the clinician must do for the remainder of the clinician must do for the remainder of the examthe exam
It offers a good opportunity for the clinician It offers a good opportunity for the clinician to get to know the patient as a person and to get to know the patient as a person and build trust with the patientbuild trust with the patient
Chief ComplaintChief Complaint
The chief complaint is often the first The chief complaint is often the first question askedquestion askedIt is the It is the most importantmost important part of the case part of the case history because the clinician is trying to history because the clinician is trying to determine the purpose for the patient’s determine the purpose for the patient’s visitvisitIt should be an open-ended questionIt should be an open-ended question Why did you come in today?Why did you come in today? Are you having problems with your eyes?Are you having problems with your eyes?
Chief ComplaintChief Complaint
FrequencyFrequency How often does this occur?How often does this occur? Constant or intermittent?Constant or intermittent?
OnsetOnset When did the problem begin?When did the problem begin? Recent or long-standing?Recent or long-standing?
LocationLocation Where is the problem located?Where is the problem located? Right eye, left eye, or both eyes?Right eye, left eye, or both eyes? Unilateral or alternating?Unilateral or alternating?
Chief ComplaintChief Complaint
DurationDuration How long does it last?How long does it last?
AssociationAssociation What other symptoms do you experience with this What other symptoms do you experience with this
problem?problem?
ReliefRelief What seems to make your symptoms go away?What seems to make your symptoms go away?
QualityQuality How would you rate the severity of your symptoms?How would you rate the severity of your symptoms?
Common Eye ProblemsCommon Eye Problems
Flashes of lightFlashes of lightFloatersFloatersHalos around lightsHalos around lightsDouble visionDouble visionHeadachesHeadaches
How often do they occur?How often do they occur? How would you rate their severity?How would you rate their severity?
Eye painEye painRednessRednessTearingTearing
Visual DemandsVisual Demands
OccupationOccupation What kind of work do you do?What kind of work do you do?
ReadingReading Do you read?Do you read?
Computer Computer Do you use the computer?Do you use the computer? How many hours per day?How many hours per day? How many days per week?How many days per week?
Visual DemandsVisual Demands
DrivingDriving Do you drive?Do you drive? Do you have problems driving at night?Do you have problems driving at night?
HobbiesHobbies What are your hobbies?What are your hobbies?
SportsSports What type of sports do you play?What type of sports do you play?
Ocular HistoryOcular History
Last eye examination (LEE)Last eye examination (LEE) TimeTime
When was your last eye examination?When was your last eye examination? LocationLocation
By whom?By whom? Particular exam findingsParticular exam findings
What was the outcome of that examination?What was the outcome of that examination?
Last prescription (LRx)Last prescription (LRx)
Ocular HistoryOcular History
Glasses Glasses AgeAge
When were your glasses last changed?When were your glasses last changed? UsageUsage
Are they for distance, intermediate, near, or all?Are they for distance, intermediate, near, or all? VisionVision
Describe your vision with your glasses.Describe your vision with your glasses. ComfortComfort
Describe your comfort with your glasses.Describe your comfort with your glasses.
Ocular HistoryOcular History
Contact lensesContact lenses Average wearing time (AWT)Average wearing time (AWT)
What is your average wearing time per day?What is your average wearing time per day? Wearing time today (WTT)Wearing time today (WTT)
How long have you worn your lenses today?How long have you worn your lenses today? Current lens typeCurrent lens type
What type of lenses do you wear now?What type of lenses do you wear now? Current lens care regimenCurrent lens care regimen
Describe your current lens care regimen, including Describe your current lens care regimen, including the solution brand.the solution brand.
Ocular HistoryOcular History
Contact lensesContact lenses AgeAge
How old are your current lenses?How old are your current lenses? UsageUsage
Are they for distance? Intermediate? near? or all?Are they for distance? Intermediate? near? or all? VisionVision
Describe your vision with your contact lenses.Describe your vision with your contact lenses. ComfortComfort
Describe your comfort with your contact lenses.Describe your comfort with your contact lenses.
Ocular HistoryOcular History
Ocular diseasesOcular diseases Have you ever been told that you have an eye Have you ever been told that you have an eye
turn or a lazy eye?turn or a lazy eye? Have you ever been told that you have Have you ever been told that you have
cataracts (CAT), glaucoma (GLC), or any cataracts (CAT), glaucoma (GLC), or any other eye disease?other eye disease?
Ocular surgeriesOcular surgeries Have you ever had any eye surgeries?Have you ever had any eye surgeries?
Medical HistoryMedical History
Last physical examination (LPE)Last physical examination (LPE) TimeTime
When was your last physical examination?When was your last physical examination? LocationLocation
By whom?By whom? Particular exam findingsParticular exam findings
What was the outcome of that examination?What was the outcome of that examination?
Systemic diseasesSystemic diseases Have you ever been told that you have diabetes Have you ever been told that you have diabetes
mellitus (DM), high blood pressure (HTN), thyroid mellitus (DM), high blood pressure (HTN), thyroid disease, heart disease, or any infectious disease?disease, heart disease, or any infectious disease?
Family HistoryFamily History
Many diseases are highly genetic in natureMany diseases are highly genetic in nature
Specifically ask the patient if any of his Specifically ask the patient if any of his family members has diabetes mellitus family members has diabetes mellitus (DM), high blood pressure (HTN), (DM), high blood pressure (HTN), glaucoma (GLC), strabismus, legal glaucoma (GLC), strabismus, legal blindness/low vision, or any other diseaseblindness/low vision, or any other disease
Record the family member that has each Record the family member that has each particular diseaseparticular disease