History Taking in Clinical Ophthalmology

By/Mohamed Ahmed El –Shafie

Assistant Lecturer in ophthalmology department KafrELShiekh University

Historyاسمع العيان

A good history commonly leads to a diagnosis

Helps you focus your examination

Indicates when/what investigations are needed

Introduce yourself. • Note – never forget patient names•Respect patient privacy.

General Approach

Try to see things from patient point of view. Understand patient mental status, anxiety, irritation or depression.

Listening

Questioning: simple/clear/avoid medical terms/leading, interrupting, direct questions and summarizing.

History Personal history

History of presenting complaint

Past history

Family history

Social history

PERSONAL HISTORY Name: To be familiar with your patient Age: Buphthalmos in infantsKeratoconus in teenageSenile cataract in old age Sex:Males as Retinitis pigmentosaFemales as Autoimmune Diseases

Address: to know socioeconomic state Telephone no: to keep contact with your patients Special habits: Sports and smoking Occupations: metal workers

COMPLAINTS

Patient Own Words

حتى لو بالعربى

Chief Complaint• The main reason push the pt. to seek for visiting a ophthalmic

consultation.

• Usually a single symptoms, occasionally more than one complaints e.g. blurred vision, swelling, pain, trauma, inflammation etc.

• The patient describe the problem in their own words.

• It should be recorded in his/her own words.

• What brings your here? How can I help you? What seems to be the problem?

How long? Involving one or both eyes? Any associated symptoms? Any similar problems before?

Analysis of complaints

COMPLAINTS Visual :*Diminution of vision as in cataract or

errors of refraction*Diplopia: uniocular or binocular*Flashes of lights as RD*Floaters as Musca volitans*Metamorphopsia as in macular diseases*Field defects as in glaucoma

COMPLAINTS Non Visual: Redness Lacrimation Discharge Itching Burning FB sensation Pain Phtophopia

PAST HISTORY Past Ocular History: MedicalTopical medications or same illness before SurgicalAny Eye operation done before Past Medical History:DMHypertensionAllergy- EczemaDrug co-morbidity

FAMILY HISTORY Certain diseases run in families as :Retinitis PigmentosaProgressive MyopiaGlaucoma

irrlevant

SOCIAL HISTORY Smoking Alcohol Occupation Home circumstances

EXAMINATION General Appearance as:

PtosisLid retractionExophthalmosMadarosis

EXAMINATION

Visual Acuity(VA)

VISUAL ACUITY

Rules It is a test for central vision only Discuss gratings with your patient Start with one eye (uniocular) Good illuminated chart with higher

contrast

VISUAL ACUITY

Methods Infants:Prefrentional lookingAsking the mother Children before school age:Shape charts Adults:Snellen E chartLandolt C chart

VISUAL ACUITY

Pin Hole test

To differentiate refractive errors from organic diseases by blocking peripheral rayes

VISUAL ACUITY

InterpretationUCVABCVA6/620/201.00

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