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

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

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

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? Are you having problems with your eyes?

Chief Complaint Frequency Onset Location How often does this occur? Constant or intermittent? Onset When did the problem begin? Recent or long-standing? Location Where is the problem located? Right eye, left eye, or both eyes? Unilateral or alternating?

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

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

Visual Demands Occupation Reading Computer What kind of work do you do? Reading Do you read? Computer Do you use the computer? How many hours per day? How many days per week?

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

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

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

Ocular 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 type What type of lenses do you wear now? Current lens care regimen Describe your current lens care regimen, including the solution brand.

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

Ocular 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 surgeries Have you ever had any eye surgeries?

Medical History Last physical examination (LPE) Systemic diseases Time When was your last physical examination? Location By whom? 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?

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