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Dr. Watson's Guide to History Taking

Introduction

The "Dr. Watson" in the title is a reference to Sherlock Holmes' sidekick. It always took Sherlock Holmes' superior sleuthing skills to solve the case, but Watson was an able assistant, and he never tired of trying to keep up with Holmes. In the medical field, the best history takers are doctors because of their superior knowledge of the subject matter, but they rely on ophthalmic medical personnel to be as thorough as possible to lay the groundwork for a thorough and efficient exam. Your skill as a history taker will increase as your knowledge of ophthalmology in particular, and medicine in general, increases.

In the "good old days" we didn't have to be concerned about the details and completeness of our history taking. Many patients came in for their "yearly exam" or were "sc" (without complaint). That sort of history taking won't fly anymore. Many insurance companies won't pay for a routine ophthalmic exam, and Medicare now uses three key components for determining the level of service and payment for an ocular exam. The components are: history taking, examination, and medical decision making. I can assure you that your ophthalmologist now considers good history taking to be a very important aspect of your job.

There are four major elements of history taking that affect the level (for billing purposes) of the exam:

CC chief complaint
HPI history of present illness
ROS review of systems
PFSH past medical, family, and social history

The different levels of examination, with regard to history, are:

Problem focused
Expanded problem focused
Detailed
Comprehensive

An example of a problem focused exam would be a 3 month pressure check on a glaucoma patient. This would involve a CC, a brief HPI, no ROS, and no PFSH. An example of a comprehensive exam might be an evaluation of a patient suspected of having a brain tumor. It would involve a CC, an extended HPI, a complete ROS, and a complete PFSH.

So, as a technician or an assistant, how do you decide which level of history taking to perform? You, as a technician, don't decide. The level of history taking is "justified" by the complexity of the patient's problem. You don't have to worry about it. If you are doing your job correctly, you will be lead into a more thorough history on the patients that need it. It is also unethical and illegal to provide a higher level of examination on a patient who doesn't need it so that the exam can be billed at a higher payment level.

This doesn't mean that you can't do a little extra to be thorough and bill at a reasonable level. Many offices try to do a complete ROS and PFSH at least once a year, but they may not bill at the comprehensive level. Billing at the appropriate level is the ophthalmologist's job. As a technician, let the patient and your ophthalmologist guide you to a good history. Your doctor should let you know if there is more specific information needed in a particular situation.

Chief Complaint (CC)

The chief complaint, simply put, is the reason why the patient has come to see the doctor. As far as payment is concerned, "a check-up" is not an acceptable reason for Medicare or for most insurance companies (although there are companies that do cover yearly exams). The CC doesn't have to be the first thing that you write down. If the patient doesn't immediately express a complaint, leave the space blank and come back to it latter in the exam. While some patients aren't very chatty at first, they think of complaints as the exam progresses.

You can also ask some leading questions. If the patient has had allergy problems recorded in past exams, you might ask if she has had any itching or redness. You might ask if the glasses seem to be doing the job, or if she is having any problems reading. You could ask if she has problems with glare at night.

The glaucoma patient coming back for a pressure check truly may not have any complaints. Just record that the patient has glaucoma and is returning for a pressure check. This is reason enough for the exam.

It is acceptable to paraphrase what the patient says. Some history takers prefer to quote the patient and enclose the patient's words in quotation marks.

Good rapport with the patient is important. Be organized in your questioning, but don't ask questions robotically. Nobody is going to want to talk to you if you charge into the room, bury your head in the chart, and fire off twenty questions. Smile! Talk about how lousy the weather has been. Look at the patient. Listen to what he has to say before you write anything down.

The patient does not have to talk to you. It is the patient's right to only talk to the physician if desired. If the patient is too chatty, be interested in the conversation, but take opportunities to re-direct the interview back to the history.

A person in the exam room with the patient may have valuable information regarding the patient's history, especially if the patient is a child or a person with a mental disability. However, CC and HPI information directly from the patient must be separated from information obtained from another person. For example, information from a child's mother can be identified by writing "The mother states that ...".


History of Present Illness (HPI)

Getting a history of the present illness means getting more details about the chief complaint. Your are trying to "qualify" and "quantify". Think of yourself as a detective. You are trying to pinpoint the problem so that the doctor can efficiently arrive at a diagnosis and a plan of action. The eight elements of the HPI and some samples are as follows. How many of them are used depends upon the nature and complexity of the problem.

Location: Where is the problem located? Right eye, or left eye? What part of the eye or vision?
Quality: Is the pain sharp or dull? Is the blind spot large or small?
Severity: Is the blind spot blacked out, or can she see through it? Is the pain unbearable or mild?
Duration: Did the decrease in vision come suddenly or gradually? When did the pain start?
Timing: Is the pain constant or intermittent? Is the vision blurry all the time, or during a certain time of day?
Context: What were you doing when the foreign body sensation started?
Modifying factors: Have you done anything to treat the problem? Did the treatment help? Does anything make the symptoms better or worse?
Associated signs and symptoms: Do you see floaters as well as light flashes?

You sometimes see the HPI elements listed in terms of the anagram "COLDER", as follows:

  • Character - this would include the "quality", "severity", "context", and "associated signs and symptoms" elements listed above

  • Onset - this would be included in the "timing" element listed above

  • Location- this would match the "location" element listed above

  • Duration - this would match the "duration" element listed above

  • Exacerbation - this would be in include the "modifying factors" element listed above

  • Relief - this would be included in the "modifying factors" element listed above

Although the "COLDER" list may be easier to remember, I think the other list does a better job of guiding you through the pertinent elements of the history.

Start with general questions and then get more specific. Don't ask more than one question at a time, such as, "Is your eye red and irritated?" Give the patient time to answer but politely guide her back to the subject if she goes off on a tangent.

The history for a patient with decreased vision might go something like this:

Tech: Hello Mrs. Jones, my name is Pat and my job is to get some information and measurements before the doctor sees you. What brings you in to see Dr. Cash today? (general question)
Pt.: Why, I've known Seymour for years. I was his first grade teacher, you know.
Tech: Wow! That's interesting Mrs. Jones. You don't look old enough to be his first grade teacher! Are you having any problems with your vision? (get back on the subject)
Pt.: I can't see!
Tech: Are you having trouble with one eye or both eyes? (location)
Pt.: Just my right eye. I can't see the newspaper, and the faces on TV are distorted.
Tech: When did you first notice a problem? (duration)
Pt.: Last Saturday I noticed I couldn't see with my right eye.
Tech: What were you doing when that happened? (context)
Pt.: I was looking out my front window at the people across the street.
Tech: Did you lose vision suddenly, or gradually? (duration)
Pt.: I had closed my left eye and realized I couldn't see.
Tech: Has your vision changed for better or worse since then? (timing)
Pt.: No, it's just bad all the time.
Tech: How much or what part of your vision seems to be affected? (quality, location)
Pt.: It's just my straight ahead vision. I can see all around it.
Tech: Is your vision completely blacked out, or can you see objects in the area that is affected? (severity)
Pt.: I can see things, but they look distorted.
Tech: Do you have any other visual symptoms? (associated signs and symptoms)
Pt.: No.
Tech: Have you done anything to treat the problem? (modifying factors)
Pt. I went to see another eye doctor who told me I have some kind of degeneration, and he told me to come here.

The questions that you ask don't always fit neatly into one of the element categories. The elements are guidelines, and all elements won't necessarily be needed in all histories.

When recording the history, it is not necessary or desirable (in the interest of time) to record everything the patient says. You will need to be a good editor, recording only what is pertinent to good coding and good patient care. Use standard abbreviations to save time and space. A record of Mrs. Jones history might look something like this:

CC: "I can't see."
HPI: Pt c/o ↓ VA + central distortion OD x 5D. No change over time. Noticed when covered OS. Dr. Smith dx'd AMD and referred.

Some follow-up visits are covered by a global time period and you don't have to be so particular about the history. For instance, follow-up visits relating to cataract surgery within a three month period are considered by Medicare to be part of surgical care and cannot be charged for. Even though "no complaints" or "doing well" is acceptable in these situations, this is not a license to be sloppy. Your ophthalmologist would still appreciate a pertinent history if the patient is having problems.


ROS Review of Systems

ROS relates to the condition of the rest of the body. The idea is that bodily systems are inter-related and that the eyes may be affected by what is going on elsewhere.

The most complete ROS involves asking symptom related questions. Instead of asking "do you have any cardiovascular problems", you would ask a series of questions such as "do you have an irregular heart beat" and "have you had any chest pain." ROS is commonly confused with PMH (Past Medical History). ROS is only symptom related, not diagnosis related. For example, diseases such as hypertension and diabetes are listed in the Medical History, not in the Review of Systems. Symptoms, such as dizziness and headaches, are listed in the Review of Systems. Think of the "S" in ROS as meaning "symptoms" instead of "systems".

Some common systems groupings are as follows, with some common questions:

  • Constitutional - Have you had any fever, fatigue, or night sweats?

  • Head, eye, ear, nose and throat (HEENT) - Have you had any vision changes, hearing changes, ear aches, sore throat, or headaches?

  • Respiratory - Have you had any shortness of breath or coughing?

  • Cardiovascular - Have you had any chest pain or palpitations?

  • Vascular - Have you had any leg pain?

  • Gastrointestinal - Have you had any vomiting, diarrhea, or constipation?

  • Genitourinary - Have you had any painful or difficult urination? Have you had any blood in your urine?

  • Metabolic/Endocrine - Have you had any cold or heat intolerance?

  • Neuro/Psychiatric - Have you had any dizziness, emotional disturbances, or headaches?

  • Dermatological - Have you had any rashes or itching?

  • Musculoskeletal - Have you had any back or joint pain?

  • Hematological - Have you had any bleeding or bruising?

  • Immunological - Have you had any recent food or environmental allergic reactions?

Many offices have a detailed form that the patient completes in the waiting room, thus saving "chair time". The doctor, the technician, or both, should initial and date the form indicating that it was reviewed.

When competing a form or asking questions, remember that an answer must be recorded, otherwise the question was not asked. In other words, a negative response must be recorded as "no", or "none", it cannot be left blank. In the same vein, remember that everything that is done to the patient must be recorded in the chart, otherwise it did not happen as far as a Medicare or insurance company chart reviewer is concerned.



Past Medical Histories

This includes the Past Ocular History (POH), Past (systemic) Medical History (PMH), and Past Surgical History (PSH). Currently treated and past medical conditions, illnesses, injuries, and surgeries should be recorded. You should record the year of onset or occurrence of older incidents, and the month and year of more recent entries. Ask specifically about eye surgeries such as cataract surgery, refractive surgery, muscle surgery, or retina surgery or treatment.

As far as the eyes are concerned, high blood pressure and diabetes are of particular importance. Patient's don't always volunteer this information. You can use the patient's medication list as a clue to their health problems. Although not always the case, it is a pretty good bet that a patient on a blood pressure medication has had high blood pressure.



Medications

The Past Medical History includes a list of current medications, the dosage, and the frequency. Some offices send the patient a reminder card of their appointment time and include a note to bring an up-to-date list of their medications. This list can be inserted directly into the chart (or photocopied). If you do this, you should check off each medication as you verify the information, and date and initial the sheet indicating that the information was reviewed.

The eye doctor will be particularly interested in knowing any blood thinning medications the patient may be taking. These medications can increase the tendency of the eye to bleed in disease processes and during surgery.

Don't overlook medications that the patient may have stopped taking some time ago. The fact that a patient had used Plaquenil for five years and stopped taking it 4 months ago is a significant piece of history.

Don't forget about over-the-counter mediations and vitamins. The doctor will want to know what vitamins the AMD patient is already taking before giving the OK for Ocuvits.

It is a good idea to record eye medications separately from other medications, so that they don't get lost in the shuffle. You need to record the strength, the dose schedule, and the last time that a glaucoma medication was used.

It is also helpful to ask if the patient has been able to use the medication as scheduled. This is called "compliance". Non-compliance is a big problem in the world of medicine. If a medication is ineffective, the doctor wants to know if the patient is actually using the medication as prescribed.


Drug Allergies

It is always important that this list be up-to-date and in a conspicuous location on the chart. This note should include the patient's reaction to the drug. It does make a difference if a patient simply had itching following a fluorescein angiogram, or if the patient went into anaphylactic shock.

An allergic reaction and an adverse reaction are not necessarily the same. A person can have an adverse reaction without having an allergic reaction. An allergic reaction is potentially more dangerous than a non-allergic, adverse reaction. An example of a non-allergic, adverse reaction would be nausea following the injection of fluorescein dye. The nausea is unpleasant, but the patient will not die from it. The patient who experiences itching, hives, and a constricted airway is experiencing a potentially life threatening allergic reaction.

Family History

With respect to ophthalmology, it is particularly important to ask about glaucoma, macular degeneration, retinal tears or detachment, strabismus, amblyopia, hypertension, and diabetes. Some professionals don't bother to ask about cataracts because almost everyone gets them if they live long enough. However, it may be useful to know about relatives who developed cataracts at a young age.


Social History

These are potentially the most awkward subjects to ask about. Instead of asking about smoking, drinking, and crack use, you might ask about tobacco products, alcohol consumption, and recreational drugs. You should record how many cigarettes are smoked daily and for how many years, and also record how many drinks are consumed daily.

The patient's occupation and hobbies are important with respect to their visual requirements. Many times their complaints are centered around the demands of their job or hobby.

Pertinent Questions

Some of the questions that you ask are determined by what kind of problem the patient has. There are "pertinent questions" that are specific questions to ask in regard to symptoms or type of exam. Pertinent questions are questions that the ophthalmologist is going to want answers to, and the doctor will have to ask them if you do not. These questions may speed the examination process by pointing in a particular direction, or they may help the doctor arrive at a diagnosis. The common diseases in each subspecialty each have their own set of pertinent questions. These are learned from experience and a knowledge of ocular diseases, and/or they can be learned from a "cookbook" of questions to ask for specific chief complaints.

Take the example of the patient complaining of floaters. Although floaters are often the benign occurrence of small opacities in the vitreous gel, floaters can be specks of blood in the vitreous secondary to the the vitreous tugging on the retina, possibly causing a retinal tear and potentially a retinal detachment. Vitreo-retinal traction is often accompanied by light flashes in the vision. If a tear has progressed to a detachment, the patient may see a shadow or a veil in the vision of the affected eye. Floaters associated with a retinal tear often come suddenly, and in mass, as opposed to a few benign floaters. Retinal tears and detachments occur more frequently in those patients who are nearsighted. Vitreo-retinal traction and bleeding occurs more often in diabetics secondary to diabetic retinopathy. This knowledge will guide you to pertinent questions.

For this patient, pertinent questions would include:

1. When did you first notice floaters?

2. Did they appear suddenly?

3. In which eye?

4. Are there many floaters, or just a few?

5. Did you see any light flashes at the time the floaters appeared?

6. Do you still see light flashes? How often?

7. Is your vision affected?

8. Do you see a curtain or veil in your vision?

9. Are you diabetic?

10. Have you ever had any eye disease or treatment?

11. Are you nearsighted? (You would want to get more precise information by reading the patient's glasses prescription. If the patient has had refractive surgery, you would want to ask if the patient was nearsighted before the surgery, and if so, the degree of nearsightedness. The degree of nearsightedness can be estimated by asking how good the vision was when not wearing glasses or contact lenses.)

12. Do you have any family history of eye disease?

Notice that pertinent questions cut across the different categories or classifications of the history. Some have to do with the chief complaint, others with the medical history, family history, or other categories.

When documenting pertinent questions, you want to record a response to each question either positively or negatively. This way, the reviewer knows that the question was asked. For example, suppose the following was the recorded history from a patient asked the above set of questions:

"Patient complains of a few floaters that appeared suddenly two days ago in the left eye."

You would not know if the patient had been asked all the questions or not. A more comprehensive record would look like the following:

"Patient complains of a few floaters that appeared suddenly two days ago in the left eye. Pt denies having flashes or any change in vision. No significant eye, health, or family history."

More examples of pertinent questions are listed at the end of this document.

Confidentiality (HIPAA)

Every patient should be able to rest assured that the information regarding his or her exam will be communicated only among authorized personnel in your office or clinic, unless the patient requests otherwise in writing. This means that it cannot be released to a relative, another doctor's office, a doctor outside of your practice, or to anyone else without the patient's written permission. We should all avoid gossiping about patients to fellow employees. Aside from breaking the spirit of confidentiality, gossiping is extremely damaging to the reputation of your organization should a patient overhear it.

HIPAA stands for the Heath Insurance Portability and Accountability Act of 1996. Although the main focus of the act was regulation of health insurance, a byproduct has been the regulation of how all medical records are handled in terms of patient privacy. Fortunately, the standards can be figured out by applying some common sense. Although some of the standards seem a bit nitpicky, they are all designed to safeguard patient privacy. Just keep in mind that if there seems to be a chance that an information "leak" can occur, then there is probably a regulation that addresses the situation. Your office or clinic may require you to attend some type of HIPPA training that can be very extensive. It is beyond the scope of this article to cover all of the possibilities, but here are a few situation that will give you an idea of what you should be thinking about in terms of patient privacy:

  • A patient's medical condition can only be discussed with or disclosed to those persons the patient has authorized to receive information. Even the patient's spouse must be authorized by the patient. The office or clinic should have an "authorized persons" information sheet signed by the patient and on file for easy access.

  • A person requesting information by telephone must be positively identified as an authorized person before patient information can be discussed.

  • Those persons in a medical office "authorized" to view the patient's information are only those persons directly involved in the patient's care. This excludes office workers, technicians, and even other doctors in the practice who are not directly involved in the patient's care.

  • No papers with the patient's name and medical information should be left in the open where unauthorized persons can view the information. This means that chart notes left on a table in view of others should be turned face down. A chart in a "rack" on an exam room door should be turned so that it is not facing outward. Medical information that is to be discarded must not be placed into a trash can without first being shredded.

  • Conversation regarding a patient's medical condition should take place behind a closed door or out of hearing distance from others.

The above list is not exhaustive, but it gives you a good idea of the extent of the regulations.

Triage

Triage is the term for the procedure you follow when a patient calls regarding an urgent or emergency situation. The term originated with the medical care of wounded soldiers during or after battle. One medic would quickly inspect each casualty and would route the soldier to a specific area according to the severity of the wound(s). Those soldiers with terminal wounds or slight wounds would not receive any immediate attention. Those soldiers needing immediate attention to save their lives would be among the first to be seen.

Triage in the ophthalmologist's office or clinic is not usually so dramatic, and the duty may fall upon a designated technician, or a specially trained receptionist or scheduler. The job requires some knowledge of ocular disease and treatment, and the procedure will vary somewhat according to the preferences of the doctor. The most common reasons for emergency calls to the office are pain, redness, and/or decreased vision, but the triage person needs more information to sort out how urgent the situation is. Here are some general guidelines for triage:

1. We will define an emergency as a situation calling for an immediate trip to the doctor's office or a trip to an emergency room. An urgent situation would call for a same day, or next day appointment in the office or clinic.

2. Acute pain associated with eyeball redness, or blurry vision, or contact lens wear, or injury would be an emergency. Acute pain associated with a surgical procedure that does not usually have post-op pain would also be an emergency. Acute pain following a scleral buckle procedure or a retinal cryopexy procedure may not be an emergency situation because pain following these procedures is common, but the patient is usually given a prescription for a pain medication. Acute pain associated with a lid lesion such as a chalazion is not an emergency situation.

3. Chronic pain or discomfort in or around the eyes might be associated with dry eyes, blepharitis, eyestrain, allergies, or light sensitivity. These are not emergency situations and may not be urgent depending upon the degree of discomfort.

4. A sudden decrease in vision, not associated with pain or redness, must be treated as an emergency situation because a retinal detachment can be the cause. As a screener, you could ask about floaters and flashes or other symptoms, but you are wasting your time, because a lack of these symptoms does not rule out a retinal detachment.

5. What about the person who suddenly discovers poor vision in one eye because the "good" eye is closed or occluded? The vision has probably been decreasing over a period of time and the person has just not noticed it until the other eye was covered, but not necessarily. This situation should be treated with a same day appointment if possible, or perhaps the next day, in other words, as an urgent situation.

6. A gradual decrease in vision is not usually an emergency situation.

7. A new complaint of distorted vision or a central blind spot should be treated as an urgent situation, with an appointment the same day if possible. Macular degeneration responds best to treatment initiated early in the process. If your doctor does not treat macular disorders, it is best to refer the patient to a doctor who does, without the intermediate stop in your office.

8. A chemical splash into the eyes is an emergency situation, but the first response should be initiated by the patient or someone nearby. The eyes must be flushed with a copious amount of water immediately, no matter what the chemical. Many work areas are now required to have an eye irrigation station. After the initial irrigation, the patient should be seen in the office or clinic, or in an emergency room.


Additional Documentation and Considerations

Age, Sex, and Race: This information should be recorded on every visit. For example: 36 y/o w/m = 36 year old white male.

Mood and Effect: This refers to the patient's interaction with others, most specifically with you and other staff members. Of course most patients are pleasant and this can be indicated with a "good" entry. If the patient's emotional state seems abnormal, an entry can be made here. As a technician, you should be careful about what you write about mood and effect. Sometimes it is more appropriate for you to verbally discuss the patient's behavior with the physician, and let the doctor write the chart entry.

Orientation: This refers to the patient's orientation with regard to person, place, and time. Does the patient comprehend who you are and what your role is? Does the patient know where he is? Does the patient know what day it is? An entry for a "with it" patient might be: "A+O x 3", meaning alert and oriented to person, place, and time.

Corrections: Should you need to make a correction, the proper procedure is to make a line through the mistake (so that it can still be read) and initial it. You should not black out the mistake and you should not white it out.

Organization: Some offices use a "cookbook" history and exam form. This is a good way to make sure that nothing is overlooked, and it is an effective way to acclimate new employees to your system. Just remember that if there is no notation, it didn't happen. It is also useful to keep the ROS and PFSH information on separate sheets in the front of the chart. For most patients, this information does not change often. The information can be reviewed and updated, and the forms can be dated and initialed.

More pertinent questions

This listing will give you an idea of what you should be asking. The individual lists may not be comprehensive for the particular disease, and the questions will vary depending upon what your eye doctor wants you to ask.

Cataracts:

1. Does glare bother you, especially when driving at night?

2. Does blurry vision limit your activities, especially reading and driving?

New patient with history of glaucoma:

1. How long have you had glaucoma?

2. Who diagnosed glaucoma?

3. Do you use eye drops? If the patient uses glaucoma drops, you will want to know how he/she has been instructed to use the drops, the last time that the patient used the drops, and the patient's compliance with the drop schedule. For example, the patient never misses a drop (100% compliance), or the patient only remembers half the time (50% compliance).

4. Have you had laser treatment for glaucoma? What kind?

5. Have you had surgery for glaucoma? Which procedure?

6. Has anyone in your family had glaucoma? If so, did the person use eye drops, have laser treatment, or have surgery for the glaucoma? Did the person go blind from the glaucoma?

7. Do you have high or low blood pressure, diabetes, thyroid disease, or high cholesterol?

8. Do you use a tobacco product or do you consume alcohol? If so, how much?

9. Have you had any eye trauma?

10. Are you now, or have you in the past used a steroid medication?

11. Are you nearsighted? (Preferably, more precise information can be obtained by reading the patient's glasses or by performing a refraction. If the patient has had refractive surgery, you may need to rely on what the patient can tell you.)

Established glaucoma patient in for a follow-up visit:

1. Are you having any eye pain or redness?

2. Has there been a change in your vision?

3. Has there been a change in your health?

4. Have you been using your drops as instructed? If not, how have you been using them?

5. Are you having any problems with your drops?

Retina disease:

1. Do you have any family history of retinal detachment, macular degeneration, or other retina disease?

2. When did you start having problems with your vision?

3. Did you notice a sudden change in your vision, or was it gradual?

4. Do you notice any distortion in your vision, such as straight lines looking crooked?

5. Are you having problems with one eye, or both?

6. Have you ever been told by another doctor that you have a retina problem? If so, when?

7. Have you ever had any treatment for a retina problem?

8. Are you taking any vitamin supplements for your eyes?

9. Are you taking any blood thinning medications?

10. Are you being treated for high blood pressure or diabetes?

11. Are you now, or have you ever taken Plaquenil?

12. Do you smoke?

13. Do you take a birth control medication?

Diabetic exam:

1. What is your average fasting blood sugar reading?

2. What was your last A1C reading?

3. Is your blood sugar well controlled?

Eyelid lesions:

1. Do you have a history of skin cancer?

2. Has there been a prior attempt at removal or biopsy?

3. Has there been any bleeding from the lesion?

4. Has there been any lash loss?

Motility (double vision) problems:

1. Is the double vision vertical, horizontal, or a combination?

2. Does the patient still have double vision when either eye is closed (monocular or binocular double vision)?

3. Does the degree of image separation change with the position of gaze (comitant or incomitant)?

4. Is the double vision present when glasses are worn?

5. Is there a history of childhood strabismus or muscle surgery?

6. Has there been a prior stroke or neurological disorder?

7. Is there a lid droop?

8. Is there a prism correction in the glasses?

Droopy eyelids:

1. Has there been prior surgery on the lids?

2. Is there any double vision?

3. Is there any oral or facial weakness?

4. Is there a family history of ptosis?

5. Is there any history of "jaw wink" (the upper eyelid jumps when the patient is chewing or talking)?

Tearing:

1. Do the tears overflow onto the face?

2. Is there any history of lacrimal, nasal, or sinus surgery?

3. Is there any history of facial fracture?

4. Is there any history of dacryosistitis (tearduct infection)?

Entropion (eyelashes turn inward)

1. Has there been any prior eyelid surgery?

2. Is there any history of skin disease?

3. Does the patient pull out lashes at home?

Thyroid eye disease:

1. When was thyroid disease diagnosed?

2. How was the thyroid disease treated?

3. When did the eyes become involved?

4. Do the eyes bulge?

5. Do you have double vision?

6. Do your eyes close all the way when sleeping?

7. Do you have any blurry vision, eye pain, or tearing?

Trauma:

In addition to the usual CC and HPI, the following information may be needed for insurance purposes:

1. Were you wearing safety glasses?

2. Did the injury occur on the job?

3. What was the exact date and time of the injury?

4. What were you doing when the injury occurred?

5. How did the injury occur?

Orbit:

1. Date of trauma if trauma related?

2. Do you have any eye pain?

3. Do you have any pain associated with opening your mouth?

4. Do you have any double vision?

5. Do you have any facial or teeth numbness?

6. Have you had cancer?

7. Have you had any previous orbital surgery?

Socket

1. When was the eye removed?

2. Why was the eye removed?

3. Is there an orbital implant?

4. When was the prosthesis made and who made it?

5. Has there been any surgery since the eye was removed? If so, when, why, and what was done?

6. Does the prosthesis fall out easily?

7. Is there any discharge from the socket?

8. Are there frequent socket infections?

Contact Lenses

1. Do you wear conventional hard. lenses, gas permeables, or soft lenses?

2. Do you wear toric, bifocal, or another type of specialty lens?

2. How many hours do you wear the lenses?

3. Do you wear the lenses while sleeping?

4. How many years have you worn contact lenses?

5. Are you wearing the lenses now? If not, when was the last time you wore them?

5. How do take care of your lenses? What solutions do you use?

6. For the Presbyope wearing contact lenses: What do you do for reading? Monovision? Glasses over the contact lenses? Bifocal contact lenses?


  1. lucyinthesky saidSun, 18 Jan 2009 00:34:52 -0000 ( Link )

    This an absolutely amazing lesson. Thank you for posting it. My mother works for an ophthalmologist, so when I was young I used to watch all these sorts of things in the office.

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  2. moktadrazu saidMon, 20 Jul 2009 13:41:02 -0000 ( Link )

    It is beneficial for the examinees as well as learners.

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  3. HABIBULLA saidFri, 12 Oct 2012 11:21:44 -0000 ( Link )

    Very good history taking

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