• allows for an organized discussion with the patient
• tells why the pateint is there to see you
• provides the opportunity for developing a doctor-patient relationship
  • crucial in building rapport and respect - the patient will respect your treatment decision more if you have established rapport
  • the patient will decide if they are going to come back and/or refer friends to you
  • patients are less likely to sue doctors that they like
• directs the clinician in prioritizing the examination
  • helps create a list of differential diagnoses
  • assists the clinician on concentrating on teh tests of procedures that are most necessary
• it helps you to know which tests need to be performed

1. case history
2. tentative diagnosis
3. specific tests
4. interpretation and analysis
5. definitive diagnosis
6. treatment plan

• provide additional information that will help in the diagnosis and treatment of the patient (systemic health, medications, etc.)
• provides a baseline for future examinations
• provides legal protection
• provides documentation for insurance companies
  • you need to ask certain quesitons in order to bill at paticular coding levels

• the examiner must know which questions to ask, how to ask teh questions and how to interpret the answers
  • knowing which questions to ask requires you to know which symptoms may cause a specific problem
  • think about the way you ask the questions
  • must interpret the answers correctly
• a proper case history takes knowledge, practice and experience!

case history NEVER ends!!

• from the time that the patient enters the room until the time they leave the office, you will be obtaining important parts of the case history
  • make sure the patient feels at east to interject pieces of data throughout the examination
  • it is possible that the patient does not remember all data during the first few minutes of the exam
• the clinician should be asking questions throught the exam as the data dictates
  • example: phoria of 6 eso at near means you should ask about binocular symptoms
  • sometimes it is necessary to repeat a question several times before you get the information that you need

guide the patient with questions that are productive and extract relevant information

you must be thinking several questions ahead of the patient, being careful to not dwell on questions or answers that are not productive

Case History Elements:

Why is demographic information important?

• demographic information is vital to the clinician
• it is critical to be familiar with the prevalence of conditions and the age that the conditions are most commonly seen when performing the case history
  • be familiar with typical ages of onset of myopia:
    • 9-10 years old (earlier in girls than boys)
    • 18-20 years (adult onset)
• it is also important to be familiar with the characteristics of conditions with lower prevalence but with severe consequences

Case History Elements:

What demographic information should you obtain?

• patient's first and last name
• birth date
• age
• race
• gender
• occupation

also, don't forget to write today's date, your name and your attending doctor's name

Case History Elements:

What are some conditions with lower prevalence but severe consequences?

• strabismus
• retinoblastoma
• color defect
• diabetes mellitus
• keratoconus
• thyroid ophthalmopathy
• optic neuritis
• hypertension
• glaucoma
• cataract
• macular degeneration

Case History Elements:

What general observations should you note?

• perform the case history as if the patient is a person, not just a pair of eyes or a complaint
• be aware of all the patient's personal and visual needs
• observe:
  • gait
  • head position
  • facial symmetry
  • skin color
  • speech
  • odor
  • weight

Case History Elements:

How should you obtain the chief concern?

• ask for the chief concern, even if it is written on intake form
• record the chief concern in the patient's own words - this helps avoid misinterpretation
• examples:
  • what brings you to our office today?
  • what is the reason for your visit today?

Case History Elements:

What follow-up questions are important to ask and how should they be asked?

Follow-up questions should be asked to clearly definte the complain and determine possible diagnosis.  The number of follow-up questions depends on teh complexity of the problem and how completely the patient can describe the problem:

• Description/quality: often obtained in CC
  
• Onset/duration: generally first follow-up question asked
  • determine when the condition first started and the type of onset (gradual vs. sudden)
  • "how long have you noticed this?"
• Frequency/timing:
  • "how often does it occur?"
  • "how long does it last?"
  • "what time of the day does it occur?"
  • "when is it worst/best?"
• Distribution/location/laterality:
  • determine if the condition is worse in one eye than the other
  • determine where the headaches are on the head
  • determine if the blur is at distance, at near, or both
  • determine if diplopia is only in certain positions of gaze
• Associated Symptoms:
  • are there any other problems with your eyes or body that might be related?
  • follow-up with specific symptoms associated with teh particular condition
• Relief/modifying factors/context:
  • has the patient tried anything to make it better?
  • what conditions make it come on or get worse?
• Severity:
  • mild, medium, severe
  • rate on a scale of 1-10
  • is the headache throbbing or dull??
  • how is the problem affecting your life?

Case History Elements:

How should you deal with secondary concerns?

• examples of how to ask about secondary concerns:
  • "is there any other problems or concerns you would like me to look at specifically today?"
  • "do you have any other concerns with your eyes or vision?
• these conditions must be explored with follow-up questions to clearly define the complaint as discussed above (DOFDAARS)
• due to your optometric training, you may find that the secondary complaint is related to the chief complaint even though the patient did not mention it when you asked about associated symptoms
• you may also ask about specific conditions, such as double vision, floaters, etc.

Case History Elements:

What benefit does personal and family ocular history provide?

• the questions in the visual and ocular history will save unnecessary time and expense due to unnecessary training
• the family history will help to provide an accurate diagnosis in many instances
• knowledge of the family history will prompt the clinician to ask patients about similar problems

Case History Elements:

What questions should you ask about personal and family ocular history?

• "When was your last eye exam?"
  • time since the last exam is important because it indicated the perceived importance of eye care on behalf of the patient
  • if the last exam was within a year, the patient may have been unhappy with teh past exam or is interested in obtaining a second opinion
• "Have you been diagnosed with any visual conditions?"
  • you may also ask about specific conditions, such as eye diseases, injuries, surgeries, etc.
• "When did you get your first pair of glasses?"
  • how long the patient has been wearing glasses aids in determining the magnitude of refractive error as well as the causes of visual loss (amblyopia)
• "Has anyone in your family had any other eye disease?"
  • ask specifically about conditions that are common, serious, or affect the eyes without any symptoms or obvious signs (diabetes, glaucoma, blindness, etc)
  • find age and treatment of family medical conditions
• satisfaction with current glasses/contacts (details to come)

Case History Elements:

What should you ask about current glasses/contacts?

• ask if they are having any problems with their current glasses/contacts:
  • how is your vision with the current glasses?
  • how is your vision while driving?  Reading?  Computer?
• determine the age of the current prescription and how often they wear them

Case History Elements:

What specific questions should you ask to follow-up on contacts?

• what type of lenses are you wearing?
• how often do you throw them away?
• do you sleep in teh lenses?
• are they comfortable?
• how is the vision wih the contact lenses?

Case History Elements:

What benefit does determining vocational and recreational needs provide to the examination??

• consideration of the visual needs, especially with presbyopes, is important for patient satisfaction
• this line of questioning will determine if the patient can benefit from sunglasses, safety eyewaer, polarized lenses, double bifocals, contact lenses, etc.
• you must follow-up by asking if their eyes bother them while performing these activities or asking how are the current glasses working for your visual needs at work and at your hobbies
  • "are there any problems that you notice with your vision while you are performing these activities?"

Case History Elements:

What questions should you ask to determin vocational and recreational needs?

"So i can decide which glasses will work best for you, I would like to ask you some questions about how you use your eyes..."

• what is your occupation/where do you work?
• how do you use your eyes at work?
• what hobbies or recreational activities do you participate in?
• what do you like to do when you aren't working?
• how many hours per day do you spend on the computer?

*always ask if they wear sunglasses or safety eyewear at appropriate times

Case History Elements:

What benefit does obtaining personal and family medical history provide?

• important to determine if there might be ocular manifestations of systemic disease
• the medical history will also aid in determining if the patient is taking medications that may affect the eyes
• use a transition sentence before asking about the medical and family health:
  • "sometimes your general health affects your eyes.  are you having any problems with your medical health?"

Case History Elements:

What are some common systemic diseases that affect the eyes?

• diabetes mellitus
• hypertension
• thyroid disease
• arthritis
• neurologic disease (MS, papilledema, myasthenia gravis, etc)

Case History Elements:

What are some follow-up questions that are important while obtaining personal and family medical history?

• when was your last medical exam?
• did the doctor find anything out of the ordinary?
• follow-up with specific health conditions that you wish to know about:
  • do you or any blood relatives have high blood pressure? diabetes? etc.
  • the number of conditions specifically mentioend depend son teh clinician and the patient population

Case History Elements:

Why is it important to determine history of medications?

What common medications do patients often not consider as meds??

• it is important to find out the medications because 1) many systemic medications affect the eyes and, 2) you will want to manage interaction with medications that you prescribe to the patient
• many medications have adverse visual or ocular effects
  • common visual side effects: decreased vision, diplopia, accommodative dysfunction, change in refractive error, color vision changes, increased light sensitivity, EOM abnormalities, ptosis, nystagmus, dry eye, ocular irritation
  • changes can affect any part of the visual system: cornea, conjunctiva, lens, pupil, retina, optic nerve or IOP
• many female patients do not consider birth control a medication so it is useful to specifically ask about the use of birth control
• many people do not consider over the counter medications to be medications
• the same medication is often used for a variety of conditions so it is important to find out why the patient is take the medication
• if not on the patient intake form, you will need to ask about alcohol consumption, tobacco use and use of recreational drugs

Case History Elements:

How should you figure out any drug-related allergies or reactions?

• identify any past drug-related allergies:
  • "do you have any allergies"
    • this is a good time to educate your patients about ocular allergy treatment
  • "do you have any allergies to medications?"
• as the patient if they have EVER had a reaction to eye drops

Case History Elements:

Why are transition statements so important?

Give some examples of transition statements:

• a transition tells the patient why their eye doctor is asking about their diabetes, etc.
• a transition lets the patient know where you are going
• a transition will educate the patient about conditions that affect the eyes
• Examples:
  • "sometimes your general health affects your eyes. Are you having any problems with your medical health?"
  • "so I can decide which glasses will work best for you, I would like to ask you some questions about how you use your eyes."

Case History Elements:

How should you greet the patient??

• call the patient by their title (Mr., Ms., Dr., etc.) and their last name
• don't call them by their first name unless they are a child or they have told you to call them by their first name
• welcome them to the office
• a SMALL amount of small talk

Case History Elements:

How is eye contact important during the exam??

• look at the patient while they are talking
  • lets them know you think what they are saying is important
• use shorthand and learn to type whiel not looking at the computer
  • too much silent (non-talking/writing) time makes the patient uncomfortable

Case History Elements:

How should you close the case history portion of the exam?

• restate the chief concern
  • this remind you what is most important
  • this reminds the patient that you remember what is most important to them
  • his transitions into the exam
• tell the patient that if they think of anything else throught the exam, to let you know

REMEMBER: case history NEVER ends!  Even though history is recorded at the top of the exam, it goes on throughout the exam

Case History Elements:

What are some common mistakes that happen during case history??

• using optometric jargon
  
  • examples: meds, ocular, systemic, hypertension, OTC
• double barreled questions
• closed questions
  • lead to yes or no answers
  • use open-ended questions and funnel
• leading questions
• not listening (the patient already told you and you ask against without acknowledging it)
• not addressing the chief complaint

Case History Elements:

It is critical that you are familiar with symptoms and their etiology:

Blurred Vision:

What are the symptoms?

• if the vision loss is gradual, it is usually refractive
• sudden vision loss typically implies more severe consequences
• occasionally the patient suddently notices a decrease in vision and reports it as sudden even though it is a refractive change

Case History Elements:

It is critical that you are familiar with symptoms and their etiology:

Blurred Vision:

What are the differentials?

• ametropia/presbyopia
• amblyopia
• accommodative dysfunction/hysteresis
• malingering
• tear debris
• anterior uveitis
• cataracts
• vitreous hemorrhage
• retinal artery or vein occlusion
• retinal detachment
• papilledema
• ischemic optic neuropathy
• optic neuritis
• systemic problems such as diabetes

Case History Elements:

It is critical that you are familiar with symptoms and their etiology:

Blurred Vision:

What are important questions?

• when did you first notice the blurriness?
• when do you notice the blurriness?  Drive? Reading? Both?
• is it in both eyes or one eye?  Which eye is worse?
• does the vision stay blurry or does it sometimes get clear?
• is there anything that makes it worse?
• is there anything you can do to make it better?

Case History Elements:

It is critical that you are familiar with symptoms and their etiology:

Headaches or Eyestrain:

What are general considerations?

• it is common to have patients referred to you from their PCP to investigate the causes of their headaches
• don't assume that the headaches have been diagnosed correctly by either the patient or the PCP

Case History Elements:

It is critical that you are familiar with symptoms and their etiology:

Headache or Eyestrain:

What are the symptoms of visual headaches?

• medium intensity
• dull pain
• occurs within 15-45 minutes of intensive use of the eyes
• the headache goes away when the visual work is ceased
• these headaches do not occur on weekends or vacations when the intense visual work does not occur
• they are typically in the brow region or around the eyes, although if excessive muscular tension occurs due to the prolonged use of their eyes, the pain may be in the back of the neck

Case History Elements:

It is critical that you are familiar with symptoms and their etiology:

Headache or Eyestrain:

What are the signs and symptoms that accompany a life or vision threatening headache?

• scalp tenderness or pain with chewing in patients over 55 (GCA)
• optic nerve swelling
• altered mentation or behavior
• stiff neck
• decreased vision
• neurological signs

Case History Elements:

It is critical that you are familiar with symptoms and their etiology:

Headache or Eyestrain:

What are some signs that are less alarming but still serious?

• a different or more severe headache (including persons who have never had headaches before or who no longer get relief from previously used medications)
• a headache that is always in the same location
• nausea and vomiting

Case History Elements:

It is critical that you are familiar with symptoms and their etiology:

Headache or Eyestrain:

What are some differentials?

• ametropia/presbyopia
• abnormal vergence ranges or phorias
• accommodative dysfunction
• aniseikonia
• environmental
• tension headache:
  • mild to moderate dull ache in occipital or frontal areas (bilateral)
• migraine headache
  • brought on by certain foods (chocolate, yogurt, cheese, nuts, wine), drugs that alter the vascular system (nitroglycerin, birth control, estrogen, light flashes, hormonal changes, and/or stress
  • disabling, throbbing headache with nausea, vomiting and hypersensitivity to environmental stimuli
  • lasts 8-48 hours
  • unilateral
  • aura or premonitory feeling can occur
• sinus headache:
  • worse when head is in a lowered position
  • steady, throbbing ache in the frontal, retrobulbar, or maxillary area
  • tenderness around sinus area
  • transillumination defect
  • other symptoms may include coughing due to post-nasal drip, a low-grade fever, and decreased sense of smell

Case History Elements:

It is critical that you are familiar with symptoms and their etiology:

Headache or Eyestrain:

What are some important questions to ask?

• when did you first notice the headache?
• how often do you get the headaches?
• are the headaches worse in the morning or afternoon?
• do you ever wake up with the headaches?
• where are the headaches on your head?
• is there anything that makes the headaches worse?
• what do you do to get rid of the headaches? (medication, sleep, discontinuance of visual task)
• are there any other things with your body that you notice happening around the time that the headaches occur?
  • you may follow this open-ended question with specifics like nausea, numbness, tingling, flashing lights, etc.

Case History Elements:

It is critical that you are familiar with symptoms and their etiology:

External Eye Symptoms:

What are the symptoms?

• itching
• pain
• irritation
• redness
• sensitivity to light
• foregin body sensation
• feeling of dryness

Case History Elements:

It is critical that you are familiar with symptoms and their etiology:

External Eye Symptoms:

What are the differentials?

• dry eye
• trauma
• viral conjunctivitis
• bacterial conjunctivitis
• allergic conjunctivitis
• contact lens induced disease (corneal ulcer or infiltrate)
• iritis
• blepharitis

Case History Elements:

It is critical that you are familiar with symptoms and their etiology:

External Eye Symptoms:

What are some important questions to ask?

• when did you first notice the redness?
• is it getting better or worse?
• is it one or both eyes?
• does it hurt? Itch? Uncomfortable?
• are the eyes sensitive to light?
• do you have discharge? If so, type?
• Are the eyes stuck shut in the morning?
• what were you doing when it started?
• have you worn contact lenses?
• has this ever happened before?
• have you been ill?
• have any friends or family member had red eyes?
• have you tried anything to make it better?

Case History Elements:

It is critical that you are familiar with symptoms and their etiology:

Diplopia:

What are the differentials?

• binocular vision problem
• neurological problem
• ametropia
• tear, cornea or lens irregularity

Case History Elements:

It is critical that you are familiar with symptoms and their etiology:

Diplopia:

What are some important questions to ask?

• when did the double vision start?
• did it start suddenly or gradually?
• how often do you notice the double vision?
• does the double vision remain if one eye is covered?
• do the objects separate up and down or side to side?

Case History Elements:

It is critical that you are familiar with symptoms and their etiology:

Spots Before the Eyes:

What are the differentials?

• vitreous liquefaction
• vitreous detachment
• retinal detachment
• migraine

Case History Elements:

It is critical that you are familiar with symptoms and their etiology:

Spots Before the Eyes:

What are some important questions to ask?

• describe the spots
• when did it start?
• how long does it last?
• has it been getting worse or better?
• if a patient reports new floaters, you should always inquire about flashes of light