Case History
Walter Huang, OD
Yuanpei University
Department of Optometry
Case History
The goal of case history is to obtain an
understanding of the patient’s problems
and needs
It consists of a series of questions to learn
about the patient, the purpose for the visit,
and the patient’s ocular health history and
general health history
Case History
Case history is the most important part of
the exam because it guides the exam by
helping to narrow down the list of tests that
the clinician must do for the remainder of
the exam
It offers a good opportunity for the clinician
to get to know the patient as a person and
build trust with the patient
Chief Complaint
The chief complaint is often the first
question asked
It is the most important part of the case
history because the clinician is trying to
determine the purpose for the patient’s
visit
It should be an open-ended question


Why did you come in today?
Are you having problems with your eyes?
Chief Complaint
Frequency


How often does this occur?
Constant or intermittent?
Onset


When did the problem begin?
Recent or long-standing?
Location



Where is the problem located?
Right eye, left eye, or both eyes?
Unilateral or alternating?
Chief Complaint
Duration

How long does it last?
Association

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?
Common Eye Problems
Flashes of light
Floaters
Halos around lights
Double vision
Headaches


How often do they occur?
How would you rate their severity?
Eye pain
Redness
Tearing
Visual Demands
Occupation

What kind of work do you do?
Reading

Do you read?
Computer



Do you use the computer?
How many hours per day?
How many days per week?
Visual Demands
Driving


Do you drive?
Do you have problems driving at night?
Hobbies

What are your hobbies?
Sports

What type of sports do you play?
Ocular History
Last eye examination (LEE)

Time
When was your last eye examination?

Location
By whom?

Particular exam findings
What was the outcome of that examination?
Last prescription (LRx)
Ocular History
Glasses

Age
When were your glasses last changed?

Usage
Are they for distance, intermediate, near, or all?

Vision
Describe your vision with your glasses.

Comfort
Describe your comfort with your glasses.
Ocular History
Contact lenses

Average wearing time (AWT)
What is your average wearing time per day?

Wearing time today (WTT)
How long have you worn your lenses today?

Current lens type
What type of lenses do you wear now?

Current lens care regimen
Describe your current lens care regimen, including
the solution brand.
Ocular History
Contact lenses

Age
How old are your current lenses?

Usage
Are they for distance? Intermediate? near? or all?

Vision
Describe your vision with your contact lenses.

Comfort
Describe your comfort with your contact lenses.
Ocular History
Ocular diseases


Have you ever been told that you have an eye
turn or a lazy eye?
Have you ever been told that you have
cataracts (CAT), glaucoma (GLC), or any
other eye disease?
Ocular surgeries

Have you ever had any eye surgeries?
Medical History
Last physical examination (LPE)

Time
When was your last physical examination?

Location
By whom?

Particular exam findings
What was the outcome of that examination?
Systemic diseases

Have you ever been told that you have diabetes
mellitus (DM), high blood pressure (HTN), thyroid
disease, heart disease, or any infectious disease?
Family History
Many diseases are highly genetic in nature
Specifically ask the patient if any of his
family members has diabetes mellitus
(DM), high blood pressure (HTN),
glaucoma (GLC), strabismus, legal
blindness/low vision, or any other disease
Record the family member that has each
particular disease