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 and the patient.

Always remember that when taking a history Information about a patient’s health can only be shared with if consent is given.

Presenting Complaint

The chief complaint sometimes called the “presenting complaint” is the main reason why 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. You may have a patient complain about decreased vision. When you ask how long the patient has been noticing the symptoms they may say years. In that case you make think that the patient needs glasses. On the other hand if the patient says that there vision decreased last night and suddenly this could indicate a more serious pathology

CPT (Third-Party Coding) requires the following 8 pieces of information when collecting a History of the presenting complaint:

1. Location: Where is the problem?

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 & Symptoms: Is it associated with a headache?

8. Timing Do symptoms come and go or are they constant? history from both the guardian/caretaker and the patient.

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.

Double Vision

Not all double vision is the same. If a patient comes in with double vision the most important thing to do is to ask the patient of the double vision is monocular or binocular.

To test this ask the patient to cover one eye and ask the patient if his double vision went away. Repeat with the other eye. if the patient does not see double with either of the eyes by themselves then the patient has binocular double vision. This is, in many cases, caused by a refractive problem. If the patient is having double vision with one of the eyes let the doctor know.

Injuries to the Eye

What injured the eye? If the eye was injured by something living then there is a greater risk for infection. There was a patient that came into the clinic who smashed a spider and the guts landed on the cornea. The patient got an infection.

Patients are always getting a foreign body in the eye. The most common is metal. How fast was the object moving? The faster the metal was moving the deeper it will be. Again, what was it made out of? Iron means rust. The doctor may need to dremel away the rust.

Past Ocular History

Ask the patient about their glasses, contact lenses, and past surgeries. Ask about relevant family histories. Ask about glaucoma, diabetes, and thyroid problems.

You need to know about past procedures. 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 affect the eyes. These are three common medical problems which are relevant to the eye.

Note: For Diabetes ask how long the patient has been diabetic, if their sugar is controlled, if there vision is stable, and what their last blood sugar reading was.

Relevant autoimmune diseases include rheumatoid arthritis and lupus.Rheumatoid Arthritis causes dry eyes.Lupus. Patients with lupus may be on plaquenil and need to have their macula evaluated.

Premature babies who have received oxygen therapy at birth have a higher chance of retinopathy.

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.

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.

Don’t overlook over the counter medication or vitamins. Eye care providers prescribe vitamins for patients with macular degeneration. Be sure to indicate what vitamins the patient is taking

Some patients know that they are on a class of medications, but not the name of the medication. This is common with diuretics. 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. These kind of medication make 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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