Presentation on theme: "Walter Huang, OD Yuanpei University Department of Optometry"— Presentation transcript:
1Walter Huang, OD Yuanpei University Department of Optometry Case HistoryWalter Huang, ODYuanpei UniversityDepartment of Optometry
2Case HistoryThe goal of case history is to obtain an understanding of the patient’s problems and needsIt 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
3Case HistoryCase 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 examIt offers a good opportunity for the clinician to get to know the patient as a person and build trust with the patient
4Chief 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 visitIt should be an open-ended questionWhy did you come in today?Are you having problems with your eyes?
5Chief Complaint Frequency Onset Location How often does this occur? Constant or intermittent?OnsetWhen did the problem begin?Recent or long-standing?LocationWhere is the problem located?Right eye, left eye, or both eyes?Unilateral or alternating?
6Chief Complaint Duration Association Relief Quality How long does it last?AssociationWhat other symptoms do you experience with this problem?ReliefWhat seems to make your symptoms go away?QualityHow would you rate the severity of your symptoms?
7Common Eye Problems Flashes of light Floaters Halos around lights Double visionHeadachesHow often do they occur?How would you rate their severity?Eye painRednessTearing
8Visual Demands Occupation Reading Computer What kind of work do you do?ReadingDo you read?ComputerDo you use the computer?How many hours per day?How many days per week?
9Visual Demands Driving Hobbies Sports Do you drive? Do you have problems driving at night?HobbiesWhat are your hobbies?SportsWhat type of sports do you play?
10Ocular History Last eye examination (LEE) Last prescription (LRx) Time When was your last eye examination?LocationBy whom?Particular exam findingsWhat was the outcome of that examination?Last prescription (LRx)
11Ocular History Glasses Age Usage Vision Comfort When were your glasses last changed?UsageAre they for distance, intermediate, near, or all?VisionDescribe your vision with your glasses.ComfortDescribe your comfort with your glasses.
12Ocular History Contact lenses Average wearing time (AWT) What is your average wearing time per day?Wearing time today (WTT)How long have you worn your lenses today?Current lens typeWhat type of lenses do you wear now?Current lens care regimenDescribe your current lens care regimen, including the solution brand.
13Ocular History Contact lenses Age Usage Vision Comfort How old are your current lenses?UsageAre they for distance? Intermediate? near? or all?VisionDescribe your vision with your contact lenses.ComfortDescribe your comfort with your contact lenses.
14Ocular History Ocular diseases Ocular surgeries 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?Ocular surgeriesHave you ever had any eye surgeries?
15Medical History Last physical examination (LPE) Systemic diseases Time When was your last physical examination?LocationBy whom?Particular exam findingsWhat was the outcome of that examination?Systemic diseasesHave you ever been told that you have diabetes mellitus (DM), high blood pressure (HTN), thyroid disease, heart disease, or any infectious disease?
16Family 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 diseaseRecord the family member that has each particular disease