Case history

Saba Akram
 Patient is encouraged to narrate his complaints.
 a record of present past events and circumstances that
are or may be relevant to a patient's current
state of health.
Types of history

1. present history
2. past history
3. family history
 Personal history
 Birth history
 Social history
 A good history commonly leads to a diagnosis
 Helps you focus your examination
 Indicates when/what investigations are needed
 History gives you almost 60% of diagnosis of diseases.
PRESENT HISTORY

1. Name, Age, gender, Occupation, location

 c.c : chief complaints
 Associated complains
2. Dimness of Vision
Mode of onset—It may be sudden or gradual:
 Sudden loss of vision commonly occurs retinal
detachment, vitreous haemorrhage etc.
 Gradual loss of vision commonly occurs in cataract,
uveitis, amblyopia etc
Retinal detachment
Vit. heamorrhages
 Duration—Short or long
For distance or near
 Seeing double objects : squint.
 Seeing flashes of light —It is usually due to retinal
disease or high myopia.
 Night blindness —It is common in vitamin A deficiency,
liver disorders (cirrhosis), retinal diseases.
Myopia
3. Pain in the Eyes
• Mode of onset—It may be sudden or gradual
• Severity and duration—It may be mild, moderate or
severe
• Relation to close work—It is common in refractive errors
 Time of the day when maximum —Eye strain is
maximum in the evening in refractive errors
• Associated nausea, vomiting, photophobia, impaired
vision. (astheopia)
4. Redness or Inflammation
• Of the eyelids
• Of the area surrounding the eye
• Of the eyeball.
5. Secretion
• Excessive normal secretion
• Type of altered secretion (discharge), e.g.
mucopurulent, purulent, ropy Common causes of
dimness of vision
• Sticking together of lids in the morning is suggestive of
conjunctivitis
• Associated crusts or flakes in the lid margin are seen in
blepharitis.
Blepharitis
6. Disturbances of the Eyeball Eyelids

• Altered position—drooping of the lids below the normal

position occurs in ptosis
• Altered direction of the margin, e.g. entropion, ectropion
• Disturbance in function, e.g. inability to close the lids
leading to exposure Direction
• Eyes are turned out, in, up or down in squint Fixation
• Eyes “shakes” due to involuntary movements as in
nystagmus.
ptosis
ectrpion
entrpion
squint
7. Headache

• Location—frontal or occipital
• Severity and type—dull or throbbing
• Relation to near work
• Time of the day when maximum
• Factors which relieve or aggravate it
• Associated nausea, vomiting, blurred vision.
PAST HISTORY

 Previous diseases (systemic + ocular)

 treatment or operation
 history of using glasses for distance or near
PERSONAL HISTORY

 tobacco
 Diet
 Blood pressure
 diabetes mellitus.
 Kidney, blood and heart diseases.
 Foci of infection in teeth, tonsils, ears and sinuses.
FAMILY HISTORY

 Diabetes mellitus
 Hypertension
 myopia
 Glaucoma
 congenital cataract
 artheritis
 Thanks