When the doctor gets the patient in his room he should be able to understand the patients complaints in seconds. To do this the doctor needs a history that is complete, concise, and relevant.

General History

A history is obtained by asking specific questions. Try to condense the patient’s story to only include pertinent facts. You need to be like a detective and search for pertinent facts. Some people may be harder to get histories from than others. Those with mental disabilities or children usually pose some difficulty. It is important that you hear the history from both the guardian/caretaker and the patient.

Presenting Complaint

The chief complaint sometimes, called the “presenting complaint”, is the main reason the patient is in the clinic.

When obtaining information about the onset of a complaint you need to know when the patient started to notice that something was not right and how quickly the symptoms came about. In general a sudden onset means that the problem is more serious.

CPT requires the following 8 pieces of information when collecting a HPI(History of present illness):

1. Location – Where is the problem? Stye on the lid? Abrasion on the cornea?
2. Duration – How long have you noticed the symptoms.
3. Context – Is is associated with any other activities.
4. Modifying factors – What makes it better or worse
5. Quality – Describe the pain, Is it an ache, an itch, foreign body sensation?
6. Severity – How would you rate your pain on a scale from 1 to 10?
7. Associated Signs and Symptoms – The is associated with a headache or light sensitivity?
8. Timing – Do symptoms come and go or are they constant?

Symptom or Sign

A sign is something that you as the clinician sees such as redness, high eye pressure, and drusen. A symptom is what the patient experiences like flashes, pain, itchiness.

Past Ocular History

Ask the patient about their glasses, contact lenses, and past surgeries.

If they have had ocular surgeries ask what kind of surgery. You may have to do some detective work here. Procedures that involve a laser would be, glaucoma (YAG to increase fluid flow), diabetes (MAP to stop new blood vessel growth), cataract surgery(YAG, to clean up a lens after it has been opacified.)

Past Medical History

Many systemic medical problems are relevant to ocular health.

Hypertension – Causes decreased vision via drusen.

Diabetes – Causes blurred vision via glucose entering the lens and neovascularization in advanced cases.

Asthma – If a patient with asthma is on Albuterol and a beta blocker then that patient can have a bronchospasm.

Autoimmune diseases – Rheumatoid Arthritis causes dry eyes. Patients with lupus may be on plaquenil and need to have their macula evaluated.

Medications

Medications can cause ocular problems such as plaquenil, which may cause damage to the macula.

Steroids are also used to treat conditions such as rheumatoid arthritis, but cause cataracts and increased IOP(Intraocular Pressure).

Some medications pose potential problems before surgery such as aspirin which thins the blood.

Some medication give you a hint on the patients past ocular history and indicate a current condition such as a patient taking lumigan being taken for glaucoma.

Eye care providers prescribe vitamins for patients with macular degeneration. Be sure to indicate what vitamins the patient is taking.

A diuretic causes more fluid to leave the bloodstream. This causes the blood pressure to drop. Diuretics are not the only medications used to treat hypertension. Beta blockers are also used to treat hypertension.

An analgesic is a medication used for pain relief. Sulfa is an analgesic. Diamox, a sulfa containing drug, is sometimes used to control glaucoma.I have seen many patients allergic to sulfa. If a patients mentions that a certain medication made them break in a rash you may consider recording that medication as an allergy.

Before getting cataract surgery male patients should be asked if they are taking sildenafil citrate aka male enhancement. This medication makes the iris floppy and difficult to perform cataract surgery on.

Social History

Knowing  a patient’s occupation is relevant. If glasses are being prescribed you need to know what their occupation is. Do they work on a computer? Do they read? Are they at risk for eye injury? These type of questions help the ophthalmologist prescribe the correct glasses for the patient.

Does the patent drink alcohol, smoke, use recreational drugs?

Family history

There are many disorders in ophthalmology that are inheritable. The most common are glaucoma, strabismus (misalignment of the eyes), and myopia. It is important to note here that secondary glaucoma is not heritable. Secondary means that it was caused by something else. Another inheritable disease is sickle cell disease. Abnormally shaped cells can cause blockage of arteries. Blockage of arteries in the eyes causes vision loss.

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