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


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 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?


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?


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)


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.


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.


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 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

Documents

Case History Walter Huang, OD Yuanpei University Department of Optometry