Module 1: Medical history taking
Discuss the importance of
and Physical examination
Introduction
Medical professionals are like
detectives. They gather, investigate,
probe, and explore subjective and
objective information about the patient
and its family and find the possible
cause of patient’s suffering. The result of
this process will direct the health care
team and the patient collaboratively
create a plan to manage the acute and
chronic medical problem. The
importance of this undertaking in the
health care practice cannot be
underestimated. Every medical
investigation starts with these two,
history taking and physical examination.
An assessment on a case based solely
from one out of the two is a dangerous
exercise of medicine where the patient
is in the losing end.
In this module we will go through the
importance, components of history
taking and physical examination, and
how to go through each step. You are
not expected to be physicians at end of
this course but you are expected to be
knowledgeable in diseases that have an
impact on vision.
 
Objectives
At the end of the module you should be
able to:
1. Summarize the method of
extracting complete medical and
ocular history.
2. Illustrate the steps in undertaking
general and ophthalmic physical
examination.
3.
complete, accurate, and concise
history taking and physical
examination.
4. Recognize common red flags in
the general medical and ophthalmic
history and physical exam results
that will help in the deduction of
reasonable diagnosis
M1 Lesson 1: Medical History Taking
Medical history taking  in an
important tool for physicians to aid in the
diagnosis and treatment of cases. This
primarily elicits information from the
patient on areas that are relevant to the
case as well as information/s that are
not apparent that the onset by may be
significant in the diagnosis and
management.
 
Goals of medical history taking
The following the 5 most important
objectives of medical history taking:
1. Identify the patient
 Medical history taking collects
demographic information about the
patient such as name, address, date of
birth, and sex. Other related information
that are collected are religion, contact
number, and person to contact in case
of emergency. While collecting the
above information one has to inform the
patient and ensure the privacy of such
critical data.
2. Identify the
practitioners who have cared for
the patient or who may care for the
patient in the future
This is necessary to take note The following are components of a
particularly if the patient was referred to medical history but the order below
you, and in any chance, you need should not dictate the sequence of the
clarification on certain aspects of the interview and only used as a guide.
patient’s history. Remember that this is a record of the
patient’s story and the interview should
At some instances, lawyers, government be more fluid. If there is a component in
agencies or insurance companies will the history that is significant in the
request for reports about the patient’s investigation of the case and needs
case. further probing you can spend more time
on it.
3. Obtain a preliminary diagnosis
1. Chief Complaint
A good medical history will enable the 2. History of Present Illness
physician to come up with differential 3. Past Medical History
diagnosis that will direct planning and 4. Family History
tailoring of physical examination as well 5. OB-Gynecology History
as laboratory and ancillary procedures. 6. Personal-social History
7. Review of Systems
4. Select therapy
 
Thorough medical history taking will
uncover previous treatment taken by
patient as well as information on the
tolerance and side effect of the
treatment to the patient’s case. Such
information can help select future
treatment.

5. Consider socioeconomic and

medico-legal factors

Proper medical history taking can give

the physician a picture of the financial
capabilities of the patient and family and
be of help in cost-containment obviating
needless test and examination
procedure. The completeness of history
is also considered and may be audited
by payers such as medical insurance
companies.
 
Components of medical history
taking

M1 Lesson 2: Ophthalmic
History Taking
Ophthalmic history taking is similar to
general medical history taking in terms
of its goals. They are conducted to
give direction in the investigation of a
case and help come up with plausible
diagnosis and plan of treatment. The
components are almost the same as
well as the content although the major
difference lies in the focus of ophthalmic
history. It emphasizes the symptoms of
ocular disease, past and present ocular
history and medications.
Components of ophthalmic history
taking
The components of ophthalmic history
taking is essentially the same with
general medical history taking except for
emphasis on ophthalmic aspects.
 
1. Chief Complaint
This is the main ocular concern of the
patient. Usage of patient’s own words
rather than medical terms is prudent to
avoid premature diagnosis.
Paraphrasing can also be done. If the
patient says eye redness record as such
rather than eye erythema or black dirt
when looking at the sun rather than
floaters because labeling of the
complains at such an early stage, one
may proceed with the wrong direction in
investigating the case.
If more than one symptom is troubling
the patient narrow it down to the main
problem and check if the other
symptoms are associated symptoms
rather than another separate complaint.
You can ask the patient what is the main
reason for the consultation, in this way
you are looking for the symptom that
bothers the patient the most. After
which, in the history of present illness,
you can ask for other ocular symptoms
that accompanies the main problem.
2. History of Present Illness
At this stage of ophthalmic history taking
you are now getting into the details of
the symptom/s. Follow the mnemonics
of OLD CARTS that was used in general
medical history taking.
Onset:
Onset pertains to initial notice of the
symptom. You can also take note in
this part if the symptom was sudden or
gradual.
Location/ Radiation; Laterality:
It is obvious that the location of the
problem is in the eye but take note that
this is an ophthalmic history taking
hence the exact location in the
eye would help like when the patient
says, “My eye hurts.” Ask where in the
eye then you can explore by saying, “Is
it in the eyelids, at the back of the eye,
area near the eye?” Explore also the
possibility of migration to other areas
that adjacent to the ocular area.
L also stands for laterality. This is very
important in ophthalmic history taking
because it is important which eye bears
the symptoms, it can be unilateral or
bilateral.
Duration; Documentation:
This would give you a clue on how long
the symptom has occurred as well as
the chronological order of
symptoms if the ocular concerns are
quite many. Also inquire about the
constancy and recurrence of the
symptom.
Documentation is also important by
asking previous photographs, which is
of value in establishing that the
complaint is not present in the past.
An example symptom would be
drooping of eyelid or in inward or
outward deviation of the eye.
Character/ Clarification:
This simply tackles the description of
the symptom and asking for
clarification to give you as much as
possible the exact picture of the
symptom. An example would be if the
patient says, “I am having eye
discharge.” You would want to know if
the eye discharge is watery or sticky and
does it have color or foul odor or does it
cause matting of the lashes.
Aggravating factors:
You want to know what the factors are
or activities that precipitated,
sustained, or made the symptom
worse. If the patient complains of a
gritty feeling in the eye you would want
to know if it occurs while using video
terminals in a prolonged period of time.
Relieving factors:
If the above factors pertain to what
possible have caused the symptoms
relieving factors are activities, factors,
or therapeutic efforts that improved
the patient’s symptom. An example
would the use of corrective lenses to
improve blurring of vision.
Timing or temporal variations:
This portion would probe into the when
the symptom occurs in association to
the timing of the day or to season.
Severity:
This explores the gravity of the
symptom. It can be described in a scale
but often in ophthalmic complaints its
severity is usually graded in it
interference with activities of daily living.
If one complains of glare and the patient
drives you can ask if the glare affects his
driving particularly at night.
Associated symptoms:
            This is an addition to OLD
CARTS to look into other symptoms
that are related or maybe related to
the primary complain. An example
blurring of vision, you can ask if was
there also glare or headache or flashes
of light. This can best navigate the
relationship of multiple complains.
3. Past Ocular History
This section probes previous eye
problems, which can be elicited by
asking use of corrective lenses, ocular
medications, ocular surgeries, eye
trauma, or amblyopia. Further explore
the 4 Ws and H of their answer, what,
when, where, why, and how.
4. Ocular Medications
Listing current and previous ocular
medications and patient response to it
including the dosage, frequency, and pursuing this section of investigation
duration of use. This will helpful in utmost sensitivity and respect to privacy
deciding the path of management and should be upheld. Information gathered
which medications to shy away from should not be revealed to third parties
particularly due to allergic reaction or except for information that put the lives
other adverse effects. of other individuals on line or those that
is required by law to be reported.
5. Past Medical History
8. Family History
Evaluation of past medical history in
ocular history taking is necessary The focus of this section is to gather
because many ocular diseases are information of family history of ocular
manifestations of or associated with and non-ocular diseases when
systemic disease. An example would genetically transmitted disorders are
be blurring of vision in a diabetic patient under consideration. Knowledge of
that is not compliant to medications. The familial systemic diseases can help keep
blurring of vision cannot solely be the investigation in the right direction
attributed to refractive problem not towards diagnosis and treatment.
related to diabetes mellitus because
fluctuations in blood sugar level can
affect refraction in all levels from the
aqueous humor, to the lens, vitreous,
and the retina.
6. Systemic Medications
Systemic medications are included for
three mains reasons first, this
provide clues to systemic disorders
that the patient might have. Secondly,
some medications can have ocular side
effects like steroids that can increase
intraocular pressure and affect clarity of
the lens. Lastly, these medications may
have interactions with ocular
medications hence such knowledge can
prevent disaster from occurring.
7. Social History
Just like in general medical history
taking social history digs into risk
factors that have ocular
connection like alcohol use, drug
abuse, sexual history including sexually
transmitted infections, and
environmental factors. Visual
requirements of patient’s job and
hobbies are also jotted down. While

M1 Lesson 3: Overview of
General Physical Examination
After exploring objective and subjective
information from the patient a medical
professional should now proceed with
the investigation to physical
examination, which is a systematic
method of gathering and evaluating
objective anatomic findings about the
patient’s condition. In this section the
physician verifies information obtained in
the medical history and search for other
clues that may have been obscured
from the patient or have not taken into
account. The key to a physical
examination is to be concise yet
accurate. For beginners a systemic
approach is recommended so as not to
miss any information. This is done by
examining each system or from head
down. But as one’s skills and knowledge
advance the systemic approach shifts to
problem-oriented or focused
assessment where the chief complaint
dictate which segment should be
performed. To be thorough, even if one
uses the systemic or problem-oriented
approach always start on the right side.
Before starting any contact with a
patient always keep in mind professional
demeanor and be courteous and
respectful. Make the patient comfortable
and relaxed by minding the environment
to which you are to undertake the
examination, Is the room to warm or too
cold? Close nearby doors or curtains.
Make sure to ask permission in every
step of the examination and possibility of
discomfort during the examination.
Provide draping and make sure your
instructions to the patient are clear. And
always wash or disinfect your hands in
the patient’s presence before
commencing and after completion of the
examination.
M1 Lesson 3: Overview of
General Physical Examination -
Modes of Examination
Modes of examination
The methodical gathering and
evaluation of anatomic findings in
physical examination is done through 4
modes of examination namely
observation, palpation, percussion, and
auscultation. The information obtained
are integrated to the medical history to
identify an intelligent and plausible
cause of the chief complaint and direct
management of the case.
 Inspection generally pertains to visual
examination and taking note of
changes in color, size, shape, presence
of elevations, irregularities and
deformities. The sense that is played
here is the sense of sight. A keen
attention to detail is necessary.
Palpation is the act of feeling the
affected area. Jotting down findings on
size of the anatomic part or of a
deformity, irregularity, or elevation.
Noting also the mobility, tenderness,
and warmth of an affected area. If there
is a presence of a mass the consistency
is also noted. Is it fluctuating, firm,
doughy, or hard? Or is it rough, nodular,
defined or ill-defned borders? The sense
of touch predominates this mode of
examination.
 Percussion is done by tapping the
area of concern with fingers, hands, or
small instrument to determine the state
of underlying structures. The action
produces a sound from which the
physician can infer the presence of
gas or fluid in a cavity.
 Auscultation is a mode of examination
that uses stethoscope to listen to
the sounds produced by organs.
M1 Lesson 3: Overview of
General Physical Examination -
General Survey
General Survey
General Survey is an overall
observation of the patient’s general
state of health, height, build, posture,
motor activity, gait, grooming, and
personal hygiene. Take note of facial
expressions, affect, and reactions to the
environment and other person. Listen to
manner of speaking, tone, and level of
consciousness. This section generally
gives you a clue on how to interact with
the patient and non-verbal information
on the case that might become valuable
in the direction of the medical care.
M1 Lesson 3: Overview of
General Physical Examination -
Vital Signs
Vital signs
Vital signs are primary measures of
body’s basic function. It basically
delineates an emergency case and
those patients from which you can take
time to examine. It rapidly identifies the
magnitude of illness and how well the
body copes. This includes blood
pressure (BP), Heart rate (HR),
Respiratory rate (RR), body temperature
(Temp). The normal values of each vital
sign vary with age, gender, weight, and
overall health.
 
1. Blood Pressure (BP)
Blood pressure is the measurement of
the force of blood against the walls
of the arteries. It is an essential clinical
value because it describes the status of
the vasculature in acute and chronic
states. It is composed of 2 numbers; the
systolic pressure which is the numerator
and the diastolic pressure is the
denominator. The unit for blood
pressure is in mmHg. With the latest
American Heart Association guideline on
normal blood pressure of an adult is less
than 120 over less than 80 mmHg. A
systolic blood pressure of 110 mmHg
and 70 mmHg is written as 110/70
mmHg.
2. Heart rate
Heart rate pertains to the number of
times the heart beats per minute. It
can be can be recorded as cardiac rate
when you listen directly to the heart
using a stethoscope placed on the chest
or pulse rate where you palpate the
bounding movement felt in an area of an
artery. The areas where pulse are
usually felt are in the area between the
angle of the jaw and neck where the
carotid area is located, and in the wrist
towards the side of the thumb where the
radial artery is located.
Normal adult heart rate is 60 to 100
beats per minute. Anything less than 60
is bradycardia or slowed heart rate and
values above 100 is considered
tachycardia or increased heart rate.
Women tend to have faster heart rate.
Infection, dehydration, stress, anxiety,
thyroid problem, shock, or certain heart
disease can cause tachycardia. But
physiologically heart rate increases with
physical exertion as well caffeine intake.
Although lower heart rate is common in
individuals who regularly exercise.
Normal heart beats are equally spaced,
not too strong and not too weak, and no
beats should be missed.
 
surface area hence larger space to
dissipate warmth. While the elderly
cannot control their body temperature as
well as younger adults.
Temperature can be measured using
thermometer that can be placed in
various parts of the body. There is a
specific thermometer used for every part
of the body like oral, axillary, surface or
non-contact, tympanic membrane or ear,
and rectal thermometers. It is the rectal
thermometer that is the closest to the
core temperature of the body.
Anything that is below the range is
labelled as hypothermia and those that
are above are labelled as fever.
Elevation in temperature is not only due
to infection, inflammation, and illness but
it can also be due to stress, dehydration,
exercise, hot environment, or immediate
intake of hot beverage.

3. Respiratory rate
Respiratory rate indicates the number
of breaths per minute. Normal adult
values fall between 12 to 20 breaths per
minute. Values outside the normal range
are abnormal but you have to take note
that normal respiratory rate values of
children are much higher depending on
their age group. This is done by
observing the rise and fall of the chest.
 
4. Body Temperature
The measure of body temperature can
be reported in degrees Fahrenheit (°F)
or degrees Celsius (°C) but in the
Philippines the latter is often used. The
normal body temperature is at 97.8 to
99.1 °F or 36 to 37.5 °C. Infants and
young children often registers lower
values particularly when placed in cold
environment because of their increased

M1 Lesson 4: Basic Ophthalmic
Physical Examination
          A comprehensive ophthalmic
evaluation includes evaluation of the
anatomic status and physiologic function
of the eye, visual system, and related
structures.
2. Pupils
The 8-Point Eye Exam
The key to any examination is to be
systematic and always perform each
element.
1. Visual acuity
 In the clinic, visual acuity is
typically measured at distance.
Otherwise, in a consult setting
outside of the clinic, it’s measured
at near. Don’t forget to have a
near card with you.
 Make sure the patient is wearing
his or her correction. Always have
a pair of +3.00 readers with you,
as many people in the emergency
room won’t have their glasses
with them. A pinhole occluder will
also reduce the impact of
uncorrected refractive error.
 If the patient is unable to see the
biggest optotype on the card, the
progression (from better to
worse) is counting fingers (CF),
hand motions (HM), light
perception (LP) with projection,
LP without projection and no light
perception (NLP).
 For children who are too young to
use Allen pictures, employ the
“central, steady, maintain (CSM)”
approach. Central: Is the corneal
light reflex in the center of the
pupil? Steady: Can the patient
continue fixating when the light is
slowly moved
around? Maintain: Can the
patient maintain fixation with the
viewing eye when the previously
covered eye is uncovered?
 Look for anisocoria. If present,
carefully check the pupil size in
both well-lit and dark conditions.
 Check the reactivity of each pupil
with a penlight or Finoff
transilluminator.
 Use the swinging flashlight test to
look for a relative afferent
pupillary defect.
3. Extraocular motility and alignment which is the distance from the
corneal light reflex to the margin
 Have the patient look in the six of the upper lid.
cardinal positions of gaze. Test  Look for lagophthalmos.
with both eyes open to assess  Note any unusual growths or
versions — repeat monocularly to lesions that may require a biopsy.
test ductions. Figure 1 below  Palpate lymph nodes and the
shows which muscle is tested in temporal artery if indicated by the
each position. history or exam.
 Use the cover/uncover test to  Measure proptosis or
assess for heterotropias. enophthalmos with an
 Use the alternate cover test to exophthalmometer.
assess for the total amount of  Perform a full cranial nerve exam
deviation. This amount minus any for patients with diplopia or other
heterotropia is the amount of neurologic symptoms.
heterophoria.
7. Slit-lamp examination
4. Intraocular pressure

 Goldmann applanation tonometry

is the gold standard and should
be used in the clinic whenever
possible.
 Outside of the clinic, Tono-Pen  Lids/lashes/lacrimal system: 
tonometry is much more practical.
 If you suspect a ruptured globe,  Normal anatomy and contours?
skip this part of the exam. Any lesions?

5. Confrontation visual fields  Conjunctiva/sclera: 

 Assess each quadrant  White and quiet? Injection?

Lesions?
monocularly by having the patient
count the number of fingers that
you hold up. If acuity is  Cornea: 
particularly poor, have the patient
note the presence of a light.  Clear? Epithelial disruptions?
 Use the colored lid of an eyedrop Stromal opacities? Endothelial
bottle to define the position of a lesions?
scotoma more accurately.
 Anterior chamber: 

6. External examination  Deep? Cell or flare?

 Look for any ptosis by measuring  Iris:

the margin-to-reflex distance,
  Round pupil? Transillumination
defects? Nodules?

 Lens: 

 Clear? Nuclear, cortical or

subcapsular cataract?

 Anterior vitreous: 

 Inflammation? Hemorrhage?
Pigmented cells?

8. Fundoscopic examination

 Optic nerve: 

 Cup-to-disc ratio (see Figure 2

below)? Focal thinning? Pallor?
Symmetric?

 Macula:

 Foveal light reflex? Drusen,

edema or exudates?

 Vessels: 

 Contour and size? Intraretinal

hemorrhage

 Periphery:

 Tears or holes? Lesions?

Pigmentary changes?