1. PATIENT PROFILE
&
CASE HISTORY
Manish Khanna
B.Optom
13th October, 2012

2. Patient Profile
 Name of patient
 Address
 Contact details
 Age
 Occupation
 Race / ethnicity
 Gender
 Hobbies / lifestyle
 Education level

3. Case History
 Communication
 The chief complaint
 Patient’s ocular history
 Patient’s ocular health
 Medications
 Allergies
 Family ocular and medical history
 Vocational and recreational visual
requirement

4. Main Objectives of a
Case History
 To elicit reasons for visit
 To ascertain patient’s expectations
 To acquire relevant background information
 To determine the specific tests or
procedures that should be performed
during the examination
 To form a tentative diagnosis

5. Communication
 Greet the patient with confidence
 Introduce yourself, be professional
 Establish a relationship of trust
 Show genuine interest
 Be courteous and respectful
 Ask open-ended questions
“What difficulties are you experiencing with
your vision?”

6. Chief Complaint
The chief complaint is usually the primary
reason for the patient seeking consultation
 “What is the reason for your visit?”
 “What brings you to the practice today?”
 “What seems to be the problem?”

7. Description of the complaint/
symptoms: Headache
 Duration
 Relief or remitting factors
 Frequency
 Associated sign and symptoms
 Location: Temporal, Frontal, and Occipital, etc.
 Laterality: RE, LE or BE?
 Onset
 Pain
 Prescription medication
 Exacerbating factors
 Severity

8. Description of the complaint/
symptoms: Blurred Vision
 Duration
 Relief or remitting factors
 Frequency
 Associated sign and symptoms
 Location: DV, NV or Both?
 Laterality: RE, LE or BE?
 Onset
 Pain
 Prescription medication
 Exacerbating factors
 Severity

9. Likely Aetiologies for Blurred
Vision:
 Ametropia/ presbyopia
 Night myopia
 Malingering
 Ocular disease conditions, e.g. cataracts, retinal disease, optic
nerve diseases
 Amblyopia
 Accommodative dysfunction Constant distance and near blur
could be refractive such as astigmatism
 Constant distance blur could be refractive such as myopia
 Intermittent near blur could be refractive such as moderate
hyperopia
 Constant near blur - presbyopia or high hyperopia
 There may be other causes of blur or even multiple causes
compounding one another Other chief complaints are explored
in a similar manner.

10. Possible Chief Complaints
Could Include
 Decreased vision
 Headache
 Eyestrain / asthenopia
 Itching
 Burning / stinging eyes
 Tearing
 Foreign body sensation
 Double vision (diplopia)
 Flashes
 Floaters

11. Patient’s Ocular History
 Last eye examination
 Previous ocular disease or trauma / injury
 Any history of ocular surgery
 Any history of strabismus or amblyopia
 Previous prescriptions including spectacles
and contact lenses

12. Patients Medical History
 Heart or kidney disease
 High blood pressure
 Diabetes
 Arthritis
 General fitness
 Headaches (those not related to vision)
 Any other systemic condition
 Last medical examination

13. Medications and Allergies
 Drug Name
 Purpose
 Dosage
 Compliance
 Side effects
 Duration of the treatment
 Cause of allergy: Environmental or
medication

14. Family Ocular and Medical
History
 Family ocular history: glaucoma, low vision
/ blindness, significant refractive errors
(exclude presbyopia)
 Family health history: heart / kidney
disease, high blood pressure, diabetes, etc.
 Patients with any family ocular / medical
history of disease should receive a
comprehensive ocular / health examination
to rule out the presence of the same
condition in the patient.

15. Vocational and Recreational
Visual Requirements
 Lighting conditions
 Computer monitor use
 Print size(s)
 Working distance(s)
 Safety / eye hazards
 In certain specialty areas, like that of low
vision for instance, these aspects of the
case history are especially important to
ensure that the individual is able to remain
as productive and functional as possible

16. Common Abbreviations Used In
Recording The Case History
 Px (or Pt) Patient  Rx Prescription
 DS Sphere  DC Cylinder
 CC Chief Complaint  h/a Headache
 DV Distance Vision  NV Near Vision
 R Right  L Left
 RE (or OD) Right Eye  LE (or OS) Left eye
 B (or binoc) Binocular  BE Both eyes
 c With  s Without
 1/52, 3/52 1 week, 3 weeks  3/12, 6/12 3 months, 6 months
 Increase  Decrease
 OK Okay  Sx Symptoms
 FOH Family ocular history  FMH Family medical history
 GH General health  Meds. Medication
 LEE Last eye examination  LME Last medical examination
 Occ. Ointment  Gutt. Drops
 BID Twice a day  TID Three times a day