A SEMINAR PRESENTATION

ON

CASE HISTORY
 
 BY
DR. ADANIHUOMWAN .O. BLESSING

DEPARTMENT OF OPHTHALMOLOGY
UNIVERSITY OF CALABAR TEACHING HOSPITAL

December 7TH, 2020.

 OUTLINE
 Introduction
 Definition

 Purpose

 Components

 A practical example.
 INTRODUCTION

 The case history is usually conducted at the beginning of the examination

and it is the time for the clinician and patient to become acquainted. The
method by which doctors gather information about a patient past and
present medical condition in other to make informed clinical decisions is
called history, the history requires that a clinician be skilled in asking
appropriate and relevant questions that can provide them with insight to
what the patient might be experiencing.
 INTRODUCTION CONTD…

 The clinician must present himself to the patient as a caring and

empathetic individual if he expects the patients to comply with his
advice, at the same time, the clinician begins the diagnostic thought
process by asking the patient appropriate questions to determine the
potential causes for the patient’s symptoms. The information is then used
in deciding the procedures the clinician will use to confirm or rule out
each potential diagnosis.
 INTRODUCTION CONTD…
 An introduction is necessary to establish the focus of your case and
provide orientation to your reader, it should consist of a few clear and
concise opening statements, which typically include information on
 Name

 Age

 Marital status

 Occupation, patients address and contact number.

 (Block and Singh.,2001)

 DEFINITION

A case history basically refers to a file containing relevant information

pertaining to an individual client or group.

Case history is the most important procedure in the entire process of

examination procedures. History taking can be mastered only after the
acquisition of a broad base of knowledge and after years of clinical
experience.

(Merriam-Webster.,2016)
 PURPOSE

 To gather information about the patients chief complaint, visual function,

ocular and systemic health and life style
 To establish caring relationship with the patient
 To begin the process of differential diagnosis
 To begin the process of patient education
( Nancy.B.Carlson.,2016)
 COMPONENTS

The case history for a typical primary care examination is divided into
three main parts:
 The interview
 The questionnaire
 The summary
 INTERVIEW

In the interview portion, the clinician asks open ended questions to

ascertain and asses the patient reason for seeking care ( the chief
complaint) and to ascertain the visual needs of the patients daily life
( visual demands) If the patient does not initially volunteer a complaint.
It is wise to ask key probing questions about his vision and visual
function (visual efficiency)
 Some important factors during an interview include :
 INTERVIEW CONTD…
Chief complaint
-Initiation: “why did you come in today” or “are you having any problems
with your eyes”
-Elaboration of chief complaint (FOLDARQ)
-For each complaint, the clinician asks about
 Frequency: How often does this occur?

 Onset: When did the problem begin?

 Location: Where is the problem located?

 Duration: How long do your symptoms last?

 INTERVIEW CONTD…

 Associated factors: What other symptoms do you experience with this

problem?
 Relief: What seems to make your symptoms go away?
 Quality: How would you rate the severity of your symptoms?
 INTERVIEW CONTD…
Patient’s visual demands
 “What kind of work do you do?”

 “What are your hobbies?”

 “Do you drive?”

Visual efficiency, if not already covered in the chief complaint

 “Can you see clearly and comfortably both far away and close up”
 QUESTIONNAIRE

It consist of series of questions to determine if the patient is at risk of

ocular or neurological disorders. During the questionnaire the clinician
asks about the patient’s previous ocular history. The clinician also gives
the patient a list of symptoms of common eye problems to find out if the
patient has ever experienced any of them. Some clinicians gather this
information in a written questionnaire that the patient fills out prior to
the examination.
 QUESTIONNAIRE CONTD…

Important factors to consider during the questionnaire section

Patients eye history

a) “When was your last exam? By whom? What was the outcome of that
examination?”
 QUESTIONNAIRE CONTD..

b) Corrective lens history

If the patient wears glasses, ask “how long have you been wearing
glasses? Are they for distance, near or both? Can you see clearly and
comfortably with them? When were your glasses last changed?” if the
patient does not currently wear glasses ask “have you ever worn
glasses, what where they for? When did you wear them, when and why
did you stop wearing them, do you wear contact lenses.
 QUESTIONNAIRE CONTD…
Patients medical history
 Have you ever had any medical attention to your eyes? Any surgery, injuries or
serious infection ?
 Have you ever worn an eye patch?
 Have you ever used any medication for your eyes?
 Have you ever been told that you have an eye turn or lazy eye?
 Have you ever been told that you have cataract, glaucoma or any other eye
disease ?
 QUESTIONNAIRE CONTD…

 How is your general health ?

 When was your last physical examination? By whom?
 Are you currently under the care of a physician for any health
condition?
 Have you been told that you have diabetes, high blood pressure,
thyroid disease, heart disease or any infectious disease ?
 QUESTIONNAIRE CONTD…

 Allergies: do you have any allergies, if yes to what, what are your
symptoms? And how are your allergies treated ?
 Drug history: Are you taking any medicate, if yes what medication, how
long have you been taking the medication, what is it for? And what dosage?
 Social history: Do you take alcohol? Do you smoke? If yes, for how long?
 QUESTIONNAIRE CONTD…

Symptoms of common eye problems :

 Have you experienced any of the following: flashes of light, floaters,
and halos around light, double vision, frequent or severe headaches,
eye pains, redness, tearing or a sandy, gritty feeling in your eyes?
 QUESTIONNAIRE CONTD…

Family history
 Has anyone in your family had cataract, glaucoma or blindness? If yes who,
when, for how long and what was the treatment ?
 Has anyone in your family had diabetes, high blood pressure, thyroid disease,
heart disease or any infectious disease? If yes, who, when for how long and
what was the treatment.
 Record all information including the negatives .
 SUMMARY

Case history concludes with a brief summary of the patient chief

complaint or complaints. The summary assures both the clinician and the
patient that the clinician understands the patients concerns and gives the
patient an opportunity to add anything that may have been missed.
 SUMMARY CONTD…

 A problem focused case history should include the patient’s reason for visit
questionnaire but the symptom that will help the clinician in the differential
diagnosis process, and a summary of the patient complains in the clinician
words.
 Is there anything else about your eyes, your general health or your family
eyes or health that you will like to tell me about?
 ( Nancy and Kurtz.,2016)
 PRACTICAL CASE

 A CASE OF REFRACTIVE ERROR AND INCIPIENT CATARACT

WITH DIABETICS
 CASE PRESENTATIONS

In the early hours of the day in February 11, 2016, at the sight for Africa eye
clinic in Darkuman, which is located region of Ghana.
 PRACTICAL CASE CONTD…

A 55 year old woman was accompanied by her daughter, presented with

blurry vision at distance, watery eyes after 10-15 minutes of reading she
has been using glasses, the last glasses she got it about 4 months ago,
but she cannot see clearly with the glasses any more, she strains to see
tiny prints
 PRACTICAL CASE CONTD…

 Patient oculo visual history: spectacle wearer, pterygium scrapping 8 months

ago
 Family oculo visual history: mum had cataract and dad had glaucoma
 Patient medical history: Patient is a type II diabetic patient (Fasting blood
sugar=180mg/dl) and hypertensive
 Family medical history: mum was diabetic and dad was hypertensive
 PRACTICAL CASE CONTD…

 Patient medical history: Patient is a type II diabetic patient (Fasting blood

sugar=180mg/dl) and hypertensive
 Family medical history: mum was diabetic and dad was hypertensive
 Last eye exam: 4 months ago
 Allergies: sulphur, chloroquine
 Medications: metformin
 Patient social history: Banker, married with 5 kids
 PRACTICAL CASE CONTD…
 Impression: refractive error
 Fundoscopy: Normal for both eyes
 Entrance VA: 20/60(OD), 20/60(OS) Near VA: N14 (OU)
 Plan: The patient was counselled and advised to see a general physician to
control her blood sugar level before returning for refraction, also the patient
was informed about the possibility of changing her lenses frequently
depending on her sugar and health status
 PRACTICAL CASE CONTD…

 Citation: Andrews Nartay: the case of refractive error with diabetics

in a 55 year old patient EC ophthalmology 7.6 (2017): 166-169
 REFERENCES

 Alex Mankowska(2013) : OT skills guide patient history Bradford School of

Optometry and Vision Science
 Andrew Nartey (2017): The case of refractive error with Diabetics. EC
ophthalmology 7.6 (2017): 166-169
 Bloch and Singh (2001): Information for Indigenous Australians.Research and
learning online
 REFERENCES CONTD…

 Daniel Kurtz (2016): Clinical Procedures for ocular examination. Dean of

Academic Affairs and Professor of Optometry College Of Optometry, Western
University Of Health Science Pomona California. p. 5-7
 Merriam Webster (2016): Merriam Webster Medical Dictionary. Springfield,
MO: Merriam Webster.
 Nancy B.C (2016): Case history. Clinical Procedure for ocular examination 4 th
ed. Emetus Professor of Optometry New England College of optometry in
 TAKE HOME
INDEPTH INSIGHT
 Thorough case history gives you the clinician a deep
understanding of the problem at hand way before testing even
commences
 A comprehensive case history accounts for 90% of the work if
properly done.
THANK
YOU