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Case History Walter Huang, OD Yuanpei University Department of Optometry.

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1 Case History Walter Huang, OD Yuanpei University Department of Optometry

2 Case History The goal of case history is to obtain an understanding of the patient’s problems and needs It consists of a series of questions to learn about the patient, the purpose for the visit, and the patient’s ocular health history and general health history

3 Case History Case history is the most important part of the exam because it guides the exam by helping to narrow down the list of tests that the clinician must do for the remainder of the exam It offers a good opportunity for the clinician to get to know the patient as a person and build trust with the patient

4 Chief Complaint The chief complaint is often the first question asked It is the most important part of the case history because the clinician is trying to determine the purpose for the patient’s visit It 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?

5 Chief Complaint Frequency How often does this occur? How often does this occur? Constant or intermittent? Constant or intermittent?Onset When did the problem begin? When did the problem begin? Recent or long-standing? Recent or long-standing?Location 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?

6 Chief Complaint Duration How long does it last? How long does it last?Association What other symptoms do you experience with this problem? What other symptoms do you experience with this problem?Relief What seems to make your symptoms go away? What seems to make your symptoms go away?Quality How would you rate the severity of your symptoms? How would you rate the severity of your symptoms?

7 Common Eye Problems Flashes of light Floaters Halos around lights Double vision Headaches How often do they occur? How often do they occur? How would you rate their severity? How would you rate their severity? Eye pain RednessTearing

8 Visual Demands Occupation What kind of work do you do? What kind of work do you do?Reading Do you read? Do you read?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?

9 Visual Demands Driving Do you drive? Do you drive? Do you have problems driving at night? Do you have problems driving at night?Hobbies What are your hobbies? What are your hobbies?Sports What type of sports do you play? What type of sports do you play?

10 Ocular History Last eye examination (LEE) Time Time When was your last eye examination? Location Location By whom? Particular exam findings Particular exam findings What was the outcome of that examination? Last prescription (LRx)

11 Ocular History Glasses Age Age When were your glasses last changed? Usage Usage Are they for distance, intermediate, near, or all? Vision Vision Describe your vision with your glasses. Comfort Comfort Describe your comfort with your glasses.

12 Ocular History Contact lenses Average wearing time (AWT) Average wearing time (AWT) What is your average wearing time per day? Wearing time today (WTT) Wearing time today (WTT) How long have you worn your lenses today? Current lens type Current lens type What type of lenses do you wear now? Current lens care regimen Current lens care regimen Describe your current lens care regimen, including the solution brand.

13 Ocular History Contact lenses Age Age How old are your current lenses? Usage Usage Are they for distance? Intermediate? near? or all? Vision Vision Describe your vision with your contact lenses. Comfort Comfort Describe your comfort with your contact lenses.

14 Ocular History Ocular diseases Have you ever been told that you have an eye turn or a lazy eye? Have you ever been told that you have an eye turn or a lazy eye? Have you ever been told that you have cataracts (CAT), glaucoma (GLC), or any other eye disease? Have you ever been told that you have cataracts (CAT), glaucoma (GLC), or any other eye disease? Ocular surgeries Have you ever had any eye surgeries? Have you ever had any eye surgeries?

15 Medical History Last physical examination (LPE) Time Time When was your last physical examination? Location Location By whom? Particular exam findings Particular exam findings What was the outcome of that examination? Systemic diseases Have you ever been told that you have diabetes mellitus (DM), high blood pressure (HTN), thyroid disease, heart disease, or any infectious disease? Have you ever been told that you have diabetes mellitus (DM), high blood pressure (HTN), thyroid disease, heart disease, or any infectious disease?

16 Family History Many diseases are highly genetic in nature Specifically ask the patient if any of his family members has diabetes mellitus (DM), high blood pressure (HTN), glaucoma (GLC), strabismus, legal blindness/low vision, or any other disease Record the family member that has each particular disease


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