This document discusses the importance of taking a thorough history in ophthalmology. It notes that a good history can often lead to a diagnosis, helps focus the examination, and indicates what investigations may be needed. It provides details on what should be included in a thorough history, such as the presenting complaint, past ocular and medical history, medications, allergies, family history, and social history. Common presenting complaints, past medical conditions to inquire about, and other relevant history topics are outlined.
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History taking in ophthalmology
1. History taking in ophthalmologyHistory taking in ophthalmology
HistoryHistory
A good history commonly leads to aA good history commonly leads to a
diagnosisdiagnosis
Helps you focus your examinationHelps you focus your examination
Indicates when/what investigations areIndicates when/what investigations are
neededneeded
Helps determine the functional impact ofHelps determine the functional impact of
the conditionthe condition
2. HistoryHistory
Record age and genderRecord age and gender
Presenting complaintPresenting complaint
History of presenting complaintHistory of presenting complaint
Past ophthalmic historyPast ophthalmic history
Past medical historyPast medical history
MedicationsMedications
Family historyFamily history
AllergiesAllergies
Social historySocial history
3. HistoryHistory
Presenting complaintPresenting complaint
History of presenting complaintHistory of presenting complaint
How long?How long?
Involving one or both eyes?Involving one or both eyes?
Any associated symptoms?Any associated symptoms?
Any similar problems before?Any similar problems before?
4. Presenting complaintsPresenting complaints
Visual disturbanceVisual disturbance
PainPain
Red eyeRed eye
DischargeDischarge
Itchy/dry/gritty eyesItchy/dry/gritty eyes
Alteration in appearanceAlteration in appearance
Ptosis, lid swelling, squintPtosis, lid swelling, squint
6. Past medical historyPast medical history
Diabetes?Diabetes?
Hypertension?Hypertension?
Rheumatoid arthritis?Rheumatoid arthritis?
Sarcoidosis?Sarcoidosis?
Asthma?Asthma?
Eczema or other skin problems?Eczema or other skin problems?
OtherOther
9. Family historyFamily history
SquintSquint
GlaucomaGlaucoma
MyopiaMyopia
CataractsCataracts
Poor vision etc.Poor vision etc.
10. Birth historyBirth history
For children onlyFor children only
PrematurityPrematurity
Forceps deliveryForceps delivery
Low birth weightLow birth weight
11. Social historySocial history
SmokingSmoking
AlcoholAlcohol
OccupationOccupation
Home circumstancesHome circumstances
12.
13.
14. Central retinal
artery occlusion,
note- pale posterior
pole (from
ischaemia and
retinal oedema) red
macula (due to
choroidal circulation
visable through
thinnest part of the
retina at macula )
18. Retinitis
pigmentosa
Leads to loss
of peripheral
vision and
night blindness
Note pale disc,
attenuated
vessels and
pigmentary
changes in the
periphery.
23. Acute angle closure glaucomaAcute angle closure glaucoma
Note red conjunctiva, hazy cornea due to corneal oedema, dilated pupil.Note red conjunctiva, hazy cornea due to corneal oedema, dilated pupil.
This patient will have a very hard eye.This patient will have a very hard eye.
24. Dendritic ulcerDendritic ulcer
Note branching pattern of stainjng with fluorescein underNote branching pattern of stainjng with fluorescein under
blue ultra violet lightblue ultra violet light
26. ExophthalmosExophthalmos
Note – lid retraction on rightNote – lid retraction on right
also bilateral cataracts as greyishalso bilateral cataracts as greyish
colour in pupils and bilateral arcuscolour in pupils and bilateral arcus
senilis (white rings around margins ofsenilis (white rings around margins of
both corneas)both corneas)