CLE 162.1 – Intro to Optometric Procedures
Notetaker: Jonathan Dong
Date: 8/30/2012, 1st hour
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Case History
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The first part of an exam, in some ways the most important.
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Problem vs. Data Based Testing - (notes in handout)
o Data-based tests are done for all patients; in an established patient, less data-based may
be done, in follow-up, even less data-based may be done.
o Problem-related tests may be done for patient complaints or for any problems that may
come up from data-based testing.
o Data-based tests may become problem-based, but problem based tests never become
problem-based.
Case History Importance
o Starting patient rapport – Introduce self, etc.
o Prioritizing concerns (what data-based tests to focus on, what problem-based tests to
do)
o Establish how to approach patient – stern or more coddled, in order to help exam go
smoothly and improve compliance
 Factors in selecting a doctor? “Above all you want to have a doctor who is a
fellow human being, whose concern for patients is actuated by the joy of serving,
regarding it as an incomparable privilege.”
 EX: A patient comes in worried about cataract surgery in a hospital where there
were bad experiences.
 EX: A patient comes in worried about the eye puff test, be reassuring… don’t lie.
 Many elderly patients, as a young doctor, learn to stay in control of the exam
situation.
o By the end of case history, have a pretty good idea of what’s going on (Ddx).
 Exam may just support what is going on from history, sometimes it contradicts,
that’s why you have to look.
o Think before you talk, no off-the-cuff remarks
 Things not to say: “Uh oh”, no guilt tripping (why didn’t they come in, why
aren’t they taking medications), remember HIPAA, show incompetence (“I’ve
never done that before”)…
Social History
 (In lab, try to act like a patient when working with other students, simulate real
life as much as possible.)
o Demographics
 Age, name, verifying address, phone, ethnicity, language, etc.
 Verifying you have the right patient, right info.
Chief Complaint
o Open ended questions: “What brings you in today”
o EHR Entry:
 Must be in the patient’s words, NOT what the doctor thinks is going on, quotes
or paraphrase
 Chief complaint, secondary complaint, tertiary complaint… etc., as many
complaints as the patient has (relevant), all will be examined.
o Closed-ended questions, questions with short answers
 May move more quickly to closed-ended questions for wordy patients
o Leading questions: Avoid – may be judgmental (ex. Medication compliance)
o Laundry List questions, questions with several options: good for patients that can’t
come up with specific answers/quiet (multiple choice)
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CLE 162.1 – Intro to Optometric Procedures
Notetaker: Jonathan Dong
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Date: 8/30/2012, 1st hour
Page2
Facilitative questions: encourage patient to keep talking (can help seem like clinician is
listening, especially if you need clarification), or if stories change.
o Summarize what they said back to the patient, before you need to write it down, just to
clarify the information and make sure it is accurate.
History of Present Illness - (description in handout)
o FOLDARQ: Frequency, onset, location, duration, associations, relief, quality
 On NextGen EHR: Pick list comes up for each option, or just type in whatever
 Must fill out at least four of the fields for each patient (insurance thing…)
o Must find some complaint that brought them in, otherwise insurance may not cover exam
(“Blurry vision without glasses”)
Ocular History
o General health questions
o Refractive history (glasses/contacts)
o Ocular health history: Family history of eye disease, any ocular medications/eye drops
Patient Medical History
o Usually a form patient has already filled out
o Past/Current illness
o Systemic medications, sometimes list
o Allergies, NKA, NKDA, NKMA, see handout
o Family ocular history (FOH), family medical history (FMH)
o MGM, PGF, other family abbreviations (maternal grandmother, paternal grandfather)
Social History
o Visual demands, work life, hobbies, whatever needs vision
o History of smoking, drug use, alcohol use, possible risk of STDs
 Remember you’re the doctor, less uncomfortable you are asking, the less
uncomfortable the patient will be
o Any caretaker relationships, parent/child, elderly patients with younger caretakers
o Make sure you know who else is in the room. Don’t just assume who the other person is.
Assess how involved that other person is with care.
Wrap Up
o Order of Case History:
 Chief Complaint: Sit square with the patient, be attentive
 Summarize CC back to patient, and put into computer
 Ask demographic/medical/social history battery while putting them into the
computer
 Summarize main concerns, then move on to exam