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History Taking in Optometry

History taking in optometry involves collecting demographic data, chief complaints, spectacle and ocular history, systemic and medical history, and family history. This helps with diagnosis, focuses the examination, and determines what investigations may be needed. There are specific procedures for taking history for different ocular conditions and departments, such as cataract and uveitis patients. For cataracts, the history focuses on gradual vision loss, halos, and risks like diabetes. For uveitis, it involves moderate to severe pain, photophobia, redness and determining risks for autoimmune disorders or infections. A thorough history collection is essential for optometry.

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5K views8 pages

History Taking in Optometry

History taking in optometry involves collecting demographic data, chief complaints, spectacle and ocular history, systemic and medical history, and family history. This helps with diagnosis, focuses the examination, and determines what investigations may be needed. There are specific procedures for taking history for different ocular conditions and departments, such as cataract and uveitis patients. For cataracts, the history focuses on gradual vision loss, halos, and risks like diabetes. For uveitis, it involves moderate to severe pain, photophobia, redness and determining risks for autoimmune disorders or infections. A thorough history collection is essential for optometry.

Uploaded by

bhuvana
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
  • Title Page
  • Introduction to History Taking
  • Outpatient History Taking Procedure
  • Contact Lens, Systemic Medication, and Allergy History
  • Special Conditions in History Taking
  • Continuing Special Populations

HISTORY TAKING IN

OPTOMETRY
BHUVANA KALYANI
A good history commonly leads to :

• Diagnosis

• Helps you focus on examination

• Indicates when/what investigation are needed

• Helps determine the functional impact of the condition


General out patient department history taking procedure

Demographic data:
- Name (for identification , filing system, friendly)
- Age (age related disease eg- children- congenital,old-senile disease)
- Gender (gender related disease)
- Address (endemic disease, social status )
- Occupation (occupation related disease) 

Chief complain (c/o) In patient’s language ( in which over comfortable language he/she comfortable to speak)
Duration of complaint
If it is involving one or both eyes?
Any associated symptoms?
Any similar problem before?
Previous medical advice and medication PTO.
General history

There are two types of complain:-


1. Visual complaints:- Sudden loss of vision, diminuation of vision , blurring of vision , photophobia.
2. Non visual complaint:- Discharge , pain , itching , swelling
Spectacle history :
• Is he/she using any spectacle
• If using since how many Days/months/years he/she using the spectacle
• Also check out present glass prescription by neutralisation of lens ( by manually or automated eg-lensometer )
glass history should must be taken if he/she is complaining of blurring of vision or diminishing of vision.

Ocular history:
• We should ask the patient if similar ocular related problem have existed before
• Previous eye surgery or eye injury
• Chronological order of major illness and major problem
• Ask the use of ocular medication if he/she is presently using.

Systemic history:
• We should ask the patient about any systemic health related history is existing or not Eg- diabeties – if patient have
diabeties and it may lead to diabetic retinopathy ( which indicate blurring of vision and related to thickening of the
retina with 500 micron)
• Hypertension
• Thyroid
• Asthama ,heart disesases,malingenent disesases.
Contact lens history :
• If patient using contact lens history we have to note it up with asking of which company
contact lens you are using 

Systemic medication history:


• Of what type medicine you are using to cure the systemic disease

Drug allergy disease history :


• We should ask the patient about you have any allergy to the drugs
• Family history
• We should ask the patient whether his mother, father , grandfather, grandmother have these disease
• Glaucoma
• Squint
• Myopia
• Cataract
• Poor vision You should also ask about your family systemic history
Birth history :
• Birth history is taken for children only The history should be proceeds as if baby birth is premature or forcep delivery or
low birth weight.
• Social history We should ask if patient is consuming
• Smoking
• Alcohol Or any occupation or home circumstances problem
All these are ask to each patient to each ocular department. Certain complaint of ocular cases are follows

Catract out patient dept history taking procedure- senile cataract case:
• Demographic data – it is seen in old patient usually above the age of 45 years
• Presenting complain-
• gradual loss of vision
• May be associated with coloured halos , glare
• History of present illness h/o of radiation, injury to affected eye, diabetic mellitus,steroid intake etc
• To rule out diseases affecting surgical treatment eg diabeties mellitus , hypertension.

Uvea out patient h/o taking procedure – acute iridocyclitis


• Demographic data
• Presenting symptoms- moderate to severe pain , photophobia, watering, redness,diminition of vision in sudden
onset.
• h/o of present illness- h/o of allergic condition like bronchial asthma, hay fever, allergic skin condition
• h/o of joint pain to rule out rheumatoid disease
• h/o of trauma to eye

• h/o of sinusitis

• Past history

• h/o of similar attacks in past

• h/o of systemic infection eg tubercolosis,leprosy,syphills etc

• h/o of non infectious disease eg collagen disorder, gout etc

• h/o of allergic and auto immune disorder


HISTORY TAKING FOR
SPECIAL POPULATION CAN
BE CONTINUED

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