Ophthalmology - How do you take an excellent history?

                                                                

History taking for any case is asking the patient questions about the complaint that he is having and then arriving at a diagnosis that will help you prescribe a medication or indicate towards a surgical solution.The following points is a detailed compilation of what complaints you may hear from patients in Ophthalmology and how you can diagnose the patients. From exam point of view these are sufficient but you may add more if needed. Clinically, the history taking must be complete from every aspect.

BIO DATA

Name: 

Father's name: 

Age: 

Gender: 

Marital Status: 

Occupation: 

Date of Admission: 

Presentation: 

My patient Mr. Ahmed S/O Mr. Nadeem,a 45 yrs, a old male, married, farmer by profession, resident of Gujranwala, presented in OPD on 20-04-2020 with the complaint of..

PRESENTING COMPLAINTS:

These can be of many types,

1)Visual Disturbance:

• Dimness of vision/Loss of vision. *.near vision/far vision    ** can be gradual (AMD is gradual in most cases) or sudden( vitreous hemorrhage),painless(vitreous hemorrhage)or painful(anterior uveitis)
• Metamorphopsia..micropsia /macropsia(posterior uveitis)
• Flashes of light: RD
• Floaters: uveitis, Vitreous Hemorrhage
• Halos:edema of cornea or lens...yellow -white
• Diplopia: Myasthenia Gravis, Extraocular palsies ,Polycoria
• Colour Vision disturbance
• Dark adaptation/night Blindness

2) Related to the eyeball and orbit

• Photophobia
• Foreign body sensation
• Deep ciliary pain
• Asthanopia,9discomfort to eye due wrong corrective lenses)
• Lacrimation
• Epiphora
• Pain in eye 
• Headache (refreactive errors ,Raised IOP, Stress and whether unilateral or generalised)
• Discharge 

1. Watery(viral conjuctivitis)
2. Mucopurulent(Chlamydial conjuctivitic)
3. Serous
4. Purulent(Nisseria Gonnorrhea Conjuctivitis)

3) Abnormal Appearance of eye:

• Redness
• Ptosis
• Proptosis
• Squint
• Enophthalmos
• Trichiasis

4)Trauma:

Note the painful or painless and gradual or sudden character of complaint.

In addition to the above complaints many other complaints may also be present.

The above information is tabulated but the presenting complaint of the patient must be stated in one single sentence with duration.For example:

Sudden painless loss of vision for one day.

HISTORY OF PRESENTING ILLNESS:

The detailed history of the presenting complaint is taken into account.

• Onset and location
• Duration
• Progression
• Aggravation factors
• Relieving factors
• Associating factors
• Time and Severity maybe added

Also ask whether the patient is Hypertensive or Hyperglycemic .

 

While writing the HOPI start with (or as indicated by you teachers) as follows:

My patient normotensive ,normoglycemic was in usual state of health 1 day ago whe he developed * (the complaint)* followed by the above sequence........

PAST OCULAR HISTORY:

For past ocular history a mnemonic is used(GST MILO)

• Glasses for near and far vision and the error
• Surgery of eye
• Trauma
• Medications used for eye (topical corticosteroids)/antibiotics
• Injections in eye Anti VEGF in diabetics
• Laser use in diabetics of for cornea in visual disturbance
• Other eye

PAST MEDICAL HISTORY:

Ask in detail for other medical problems that the patient was facing or is currently facing .

Some are significant as:

• DIABETES (ask for Glucose levels and control over in the past,Note the medications being used for control of diabetes)
• HTN(ask for their BP measurements over the past months.Note the medications used for the control of blood pressure)
• TB
• Blood cancers
• Autoimmune diseases (graves disese)
• IHD (ANTI COAGULATION DRUGS use)
• Stroke
• Asthma/COPD(respiratory complications for surgery and the oral corticosteroids use)
• Arthritis(Steroid overuse)

PAST SURGICAL HISTORY:

Ask for past surgeries if any.

DRUG HISTORY:

This is a very important part of history .Although we have been discussing the drugs in past medical history but we must know the drugs that were taken orally or topically for 

• Diabetes
• HTN
• Asthma
• Eye disorders
• etc

For oral drugs: Type of drug ,dosage and duration of drug must be noted.

For topical drugs: type of drugs , dosage and duration must be noted.

note the same for any injections in eye too.

FAMILY HISTORY:

Ask for any history of 

• Congenital Cataract
• Retinoblastoma
• Squint
• Glaucoma
• Night Blindness
• Retinitis Pigmentosa

PERSONAL HISTORY:

Ask for the use of

• Tobacco
• Alcohol
• eating habits 
• sleeping habits
• bowel and bladder function

BIRTH HISTORY:

More important in Children. Birth trauma if any that may be the cause of squint.

SOCIOECONOMIC HISTORY:

Ask for the socioeconomic background of the patient. To have an idea you may ask the details about his family income and details of his/her house i.e. if it's rented or his/her own property.

So this is a detailed compilation .It may appear long but with one reading, it will be easier next time when you are actually taking the history of patient.

BEST OF LUCK.