Ophthalmology

Ocular History

INTRODUCTION
The history should be HIS STORY and not what the physician
wants to hear.
How to begin:
o Welcome the patient
o Introduce yourself
o Ensure comfort and privacy
Signs vs Symptoms :
o Signs : what you observe; objective
o Symptoms : what patient relays; subjective

OCULAR HISTORY

Present Complaint
History of Present Illness
Review of Systems
Past Medical History
Medications
Allergies
Family History
Social History

CHIEF COMPAINT
Reason why the patient came in
o be concise, avoid details
Taken from the patient him/herself or from relatives/guardians

HISTORY OF PRESENT ILLNESS

Get more details from the chief complaint
Use open-ended questions
Establish good flow of information
Quantify and Qualify (QQ)

8 Elements of HPI
1. Location left or right eye, front or back of the eye
2. Quality burning pain, heaviness (glaucoma)
3. Severity glaucoma accompanied by nausea and vomiting
4. Duration how long has the problem been occurring
5. Timing when the patient perceives the problem; every morning,
every other day, etc
6. Context conditions in which the problems arise
7. Modifying factors
8. Associated signs and symptoms
Start with general questions, and then get more specific
Do not ask more than one question at a time, like Are your eyes
irritated and have discharge?
Give the patient time to answer the question
Politely guide him/her back to the subject if he/she goes off on a
tangent
Do not record everything the patient says in the history
Think of COLDER
Character quality, severity, context, associated signs and
symptoms
Onset Timing
Location
Duration
Exacerbation Modifying factors
CONSTANTINO

Reliefs Modifying factors

REVIEW OF SYSTEMS
Relates to the condition of the body
o Blurring of vision associated with high cholesterol
o Think of this as a review of symptoms
o Most complete ROS involves asking symptoms-related
questions.
Ex: In cataract patient Is your blood sugar elevated?
PAST MEDICAL HISTORY
Past Ocular History (e.g trauma, itchiness)
Past Systemic Medical History
Past Surgical History
o Indicate which eye, what kind of surgery, when the surgery
happened, the institution, name of the doctor, if possible
MEDICATIONS
List of current medications
Dosage
Frequency
o There are medications that are contraindicated or contain
side effects
o Use of steroids like in chronic asthma develop cataract or
glaucoma
o Drugs containing phenylamine are contraindicated to
patients with glaucoma because it exacerbates the condition
by increasing intraocular pressure
Allergies
o Drug allergies
o Asthma (some drugs are contraindicated like drugs which
exacerbate asthma)
FAMILY HISTORY

Glaucoma
Retinal detachment
Diabetes
Hypertension
Myopia

SOCIAL HISTORY
Tobacco consumption
o usually leads to dry eyes and early cataract formation
Alcohol use
Recreational drugs
Occupation
Hobbies
o Nature of work of patient (occupation hazards) should be
considered in prescribing eyeglasses
o E.g. using computer or watching TV would dry the eyes, so,
call center agents usually have dry eyes and foreign body
sensation
CONFIDENTIALITY
Remembering confidentiality is the most important part of the
history.

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SAMPLE CONVERSATION
Intern: Good morning Mrs. Cruz! I am Jose Mercado , your intern.
We are going to talk about your problem. What brings you to the ER
today?
(chief complaint/general question)
Patient: Why? I have known Alberto for years. I was his high school
teacher, you know.
(going off topic)
I: Wow! Thats interesting Mrs. Cruz! You dont look old enough to
be his teacher. Are you having problem with your vision?
(getting back to the subject)
Px: I cant see!
I: Are you having trouble with one or both eyes?
(location)
Px: Just my left eye. I cant read the newspaper and the faces on TV
are distorted.
I: When did you first notice the problem?
(onset)
Px: Last Friday I noticed I couldnt with my left eye.
I: What were you doing when that happened?
(context)
Px: I was looking out my front window at the person selling
vegetables across the street.
I: Did you lose your vision suddenly or gradually?
(duration)
Px: I closed my right eye and realized I couldnt see.
I: Has your vision changed for better or worse since then? (timing)
Px: No, its just bad all the time.
I: How much or what part of your vision seems to be affected?
(quality, location)
Px: Its just my straight ahead vision.I can see all around it.
I: Is your vision completely blacked out, or can you see objects in the
area affected?
(severity central, peripheral vision or total blindness, color)
Px: I can see things, but they look distorted.
I: Do you have any other visual symptoms?
(associated signs and symptoms)

Note: The questions that you ask dont always fit neatly into one of
the element categories. The elements are guidelines, and all
elements wont necessarily be needed in all histories.

SRS QUESTIONS
1. Percentage of doctors that interrupt the patient after the
first question is?
a. 60 %
b. 57 %
c. 22 %
2. Number of seconds until doctors interrupt patients before
they complete their opening statement
a. 60
b. 57
c. 30
d. 18
3. Percentage of patients who went back on to complete their
statement is?
a. 80%
b. 43%
c. 17%
d. 2%
4. The chief complaint was blurring of vision on the RE (OD).
The history of a 66y/o non-diabetic non-hypertensive patient
complaining of gradual painless blurring of vision which is
worsen by exposure to sunlight, but have better vision at
night. The key word that meant it is a non-emergency in
nature is?
a. gradual painless
b. worsen by sunlight
c. blurring of vision
d. better night vision
5. The patient walks in with complaint of being hit/splash by
the battery solution coming from the truck battery that
exploded.
a. get a good history
b. perform a proper PE
c. instill anesthetic
d. call the ER resident
e. irrigate immediately
6. The jolly overweight lady whose chief complaint is double
vision, you must ask for:
a. social history
b. past medical history
c. medications
d. family history
e. all of the above
7. Which is more dangerous?
a. allergic reaction
b. adverse reaction

Px: No.
answers: B, D, D, A, D, E, A
I: Have you done anything to treat the problem?
(modifying factors likeusingeyedrops)
Px: I went to see another eye doctor who told me I have some kind
of degeneration, and he told me to come here.

CONSTANTINO

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