眼科学教学课件：Ocular history taking

1、 Before going to examining the patients eye it is very essential to take a careful history of ocular and relevant other complaints Although it is almost similar to the general medical history that you have learned in Medicine, ophthalmic history naturally emphasizes symptoms of ocular disease, prese

2、nt and past ocular problems, related systemic disorders and ocular medications. The history is intended to elicit any information that might be useful in evaluating and managing the patient. It may be as brief or extensive, as required by the patients particular problems. To provide an overview of o

3、cular history taking to gather pertinent information that will help the physician diagnose and treat the patient. document an effective ophthalmic history Demographic data, including name, date of birth, sex, race and occupation Chief complaints and history of present illness Review of systems Past

4、ocular history including prior eye diseases, injuries, diagnosis, treatments, surgeries and ocular medications Past systemic history including allergies, used medications and any adverse reactions, pertinent medical problems and hospitalizations Family history including poor vision and its cause if

5、known, and other familial ocular and relevant systemic diseases Social history also should be noted. the main problem for which the patient has come in. “Are you having any particular problems with your eyes?” “你的眼睛有什么不好？” There are eight elements that make up the history of present illness (HPI). 1

6、.Location: Anatomically or directionally. Where the problem occurs. Which eye is bothering you? ( in the right eye or the left side of the vision) 2.Quality: Describe the problem in detail. pain is dull or sharp, vision is doubled or blurry 3.Severity: On a scale of 1 to 10, how bad is the pain? 4.D

7、uration: How long has it been going on? Did it come suddenly or gradually? 5.Timing: Does it occur all the time or just sometimes? When? For how long? 6.Context: What were you doing when this started? 7.Modifying factors: What seems to make it better or worse? What have you tried to correct the prob

8、lem? Did that help? 8.Associated signs and symptoms: Do other symptoms or problems occur along with this? Transient visual loss (vision returns to normal within 24 hours, usually withih 1 hour) 1.Few seconds (usually bilateral): papilledema 2.Few minutes: amaurosis fugax (transient ischemic attack;

9、unilateral), vertebrobasilar artery insufficiency (bilateral) 3.10-60 minutes: Migraine (with or without a subsequent headache) Visual loss lasting longer than 24 hours Sudden, painless loss 1.Retinal artery or vein occlusion 2.Ischemic optic neuropathy 3.Vitreous hemorrhage 4.Retinal detachment 5.O

10、ptic neuritis (usually pain with eye movement) Gradual, painless loss (over weeks, months, or years) 1.Cataract 2.Refractive error 3.Open-angle glaucoma 4.Chronic retinal diseases (AMD, DR) 5.Chronic corneal disease (corneal dystrophy) 6.Optic neuropathy/atrophy (CNS tumor) Painfull loss 1.Acute ang

11、le-closure glaucoma 2.Endophthalmitis 3.Corneal ulcer 4.Optic neuritis (usually pain with eye movement) 5.Uveitis Posttraumatic visual loss 1.Eyelid swelling 2.Corneal irregularity 3.Hyphema 4.Ruptured globe 5.Traumatic cataract 6.Lens dislocation 7.Retinal/vitreous hemorrhage 8.Retinal detachment 9

12、.Traumatic optic neuropathy 10.CNS injury Constitutional: unexplained weight loss or gain, loss or increase in appetite, general feeling of being unwell, unexplained fever Ears, nose, mouth, throat: ringing in the ears, hearing problems, difficulty swallowing, dizziness or loss of balance Cardiovasc

13、ula: irregular heart beat, pain, pressure, or tightness in the chest, heartburn Respiratory: difficulty breathing, shortness of breath, awakened from sleep, gasping for breath, persistent cough, an exposure to tuberculosis Gastrointestinal: a change in bowel habits; black, sticky stools; bloody stoo

14、ls; unexplained nauses and/or vomiting Genitourinary: frequent or painful urination Musculoskeletal: aching joints, muscle weakness, broken bones Integumentary (Skin and/or breast): any change in a mole; new growths; rashes; Neurological Psychiatric Endocrine: frequent urination, dry mouth, dizzines

15、s between meals Hematological/lymphatic: bleeding that was difficult to stop Allergic/immunologic Ask about the patients medical history first, followed by the medications. The medical history will include items such as hospitalizations, surgeries, injuries, illness, pregnancy, and childbirth. Past

16、medical history Have you had any type of surgery? What? When? Were there any problems afterward, such as uncontrolled bleeding? Have you had any serious illness? What? When? Were you hospitalized? Have you had any serious injuries? What? When? Were you hospitalized? Women: do you have children? Were

17、 the pregnancies and deliveries normal? Medications: What medications do you use? How often do you take them? Allergies(drugs, inhalants, contactants) When taking the family history, you are looking for serious illness and major conditions among the patients blood relatives. The spouse is not a blood relative. In eye care, We are most interested to know if there is a family history of glaucoma, cataract, macular degenerat