history taking in optometry

1. HISTORY TAKING IN
OPTOMETRY
SAHIBZADA HAKIM ANJUM NADEEM
DEPARTMENTAL COORDINATOR,
DEPARTMENT OF OPTOMETRY AND VISION SCIENCES
CEO ANJUM EYE CARE & OPTICAL COMPANY
OPTOMETRIST, AL-KHAIR EYE HOSPITAL LAHORE
CO-INCHARGE OTTC, OPTICIAN, REFRACTIONIST, COAVS
EMAIL: SHANJUM92@GMAIL.COM

2. WHAT IS HISTORY TAKING
• Asking questions of patients to obtain
information and aid diagnosis.
• Gathering data both objective and subjective
for the purpose of generating differential
diagnoses, evaluating progress following a
specific treatment/procedure and evaluating
change in the patient’s condition or the
impact of a specific disease process.

3. “Always listen to the
patient they might be
telling you the
diagnosis”.

4. KEY PRINCIPLES OF PATIENT
ASSESSMENT
•It is estimated that 80% of diagnoses
are based on history taking alone.
•Use a systematic approach.
•Practice infection control techniques.
•Establish a rapport with the patient.
•Ensure the patient is as comfortable as
possible.
•Listen to what the patient says.

5. •Ensure consent has been gained.
•Maintain privacy and dignity.
•Summarise each stage of the history
taking process.
•Involve the patient in the history taking
process.
•Maintain an objective approach.
•Ensure that your documentation (of the
assessment) is clear, accurate and

6. HISTORY TAKING IN
OPTOMETRY
History:
A good history commonly leads to
a diagnosis
Helps you focus your examination
Indicates when/what
investigations are needed
Helps determine the functional
impact of the condition

7. HISTORY
Demographic Data
Presenting complaint
History of presenting complaint
Past ocular history
Past medical history
Drug History
Family history
Allergies
Social history
Review of Systems
Summary of History
Patient Questions/Feedback

8. DEMOGRAPHIC DATA (DD)
Name
Address
Phone number
Age
Gender
Occupation
Religion
Marital status
Hobbies

9. PRESENTING COMPLAINT(PC)
1.Symptoms check - which symptoms should
always be asked about?
i. Asthenopia
ii. Headaches
iii. Pain or burning
iv. Diplopia
v. Flashes and floaters - especially high
myopes
vi. Red eyes / Discharge
vii. Itchy/ gritty eyes / dry eyes
Adapt questions to patient's age e.g.
driving/school board

10. 2.Distant Vision and Near Vision - possible
causes of blurring
i. constant DV blur - myopia
ii. headaches caused by squinting
iii. nuclear sclerosis
iv. intermittent DV blur - young diabetics
v. variable myopia
vi. pseudomyopia
vii. intermittent NV blur - presbyopes
viii. DV and NV blur - astigmatism
ix. pathology e.g. cataract / maculopathy

11. HISTORY OF PRESENTING
COMPLAINT
How should you question the patient about any
complaints they have?
“LOFTSEA”
What does LOFTSEA stand for?

12. L = location / laterality
O = onset
F = frequency / occurrence
T = type and severity
S = self treatment and its
effectiveness
E = effect on patient
A = associated / secondary
symptoms

13. LOFTSE
A
Location /
Laterality
Headache - where does it hurt
Blurred vision - one or both eyes? near or
distance?
Diplopia - particular direction?
Onset Sudden or Gradual?
Gradual onset - suggests change in refractive
status or cataract = less likely to be major
concern
Sudden changes - indicate pathology e.g.
vascular problems / retinal detachment
Frequency &
Occurrence
How often does it happen and for how
long?
e.g. highly hyperopic patient may report

14. if it is a problem of visual origin, when do
symptoms most likely occur?
Reading , watching TV , driving ,more during
the week and less during weekends , start
midday and gradually get worse
Type &
Severity
headache - throbbing, sharp or dull?
blurred vision - constant or intermittent?
partial or total vision loss?
diplopia - horizontal or vertical? disappear
when close one eye?
Self
Treatment &
its
effectiveness
does anything make it go away?
if patient done nothing about it might
be a minor problem

15. Effect on
Patient
Does it effect your everyday life?
- less confident driving
- can't see board at school
- difficulty reading
have you told your GP - if referral
from GP write a reply even if no
problems
Associated
OR Secondary
Symptoms
Any other difficulties?
May or may not be associated with
Chief Complaint

16. If the patient complains of pain, use the
'SOCRATES' method of questioning;
Site: Unilateral/Bilateral
Onset: When did it start, was it
constant/intermittent, gradual/ sudden?
Character: What is the pain like e.g. sharp, burning,
tight?
Radiation: Does pain radiate/move anywhere?
Associations: Is there anything else associated with
the pain e.g. sweating, vomiting
Time course: Does it follow any time pattern, how
long the eye has been red?
Exacerbating/relieving factors: Does anything make
it better or worse?
Severity: How severe is the pain, consider using the

17. PAST OCULAR HISTORY
(POH)
Ask about previous ophthalmological problems
including:
Poor vision since birth or during childhood
Refractive errors
History of lazy eye/amblyopia
Recurrent ocular problems, particularly
inflammatory (iritis) and herpes simplex
keratitis
Problems associated with contact lens wear
(e.g. bacterial keratitis). Check for overwear
(using daily wear contact lenses for more than
1 day) and if the correct contact lens solution

18. Recent cataract surgery (to look for
complications of surgery such as
endophthalmitis, wound infection,
intraocular lens displacement causing
a sudden drop in visual acuity)
Past or recent refractive/corrective eye
surgery
Previous history of trauma to the eye
(associated with cataract, glaucoma,
retinal detachment)

19. PAST MEDICAL HISTORY (PMH)

20. DRUG HISTORY (DH)

21. FAMILY HISTORY (FH)
Enquire if there's a family history of any of these;
Squint
Glaucoma
Cataracts
Poor vision
Amblyopia
Refractive errors
Ocular albinism and oculocutaneous albinism
Diabetes
Hypertension
Juvenile macular dystrophies
Cataract , Retinal / Corneal dystrophies , Retinal
detachment

22. BIRTH HISTORY (BH)
For children only:
Prematurity
Forceps delivery
Low birth weight

23. ALLERGIES
Enquire if patient have known allergy to any
drug e.g:
Antibiotics
Hay fever
Any other medication

24. SOCIAL HISTORY (SH)
• Knowing a patient’s occupation is relevant. If
glasses are being prescribed you need to know
what their occupation is. Do they work on a
computer? Do they read?
• Are they at risk for eye injury? These type of
questions help the ophthalmologist prescribe the
correct glasses for the patient.
• Does the patent drink alcohol, smoke, use
recreational drugs?

25. REVIEW OF SYSTEMS (ROS)
Gather a short amount of information regarding the other
systems in the body that are not covered in your History of
Presenting Complaint (HPC). These are the main systems
you should cover:
• Cardiovascular System
• Respiratory
• Gastrointestinal tract
• Neurology
• Genitourinary/renal
• Musculoskeletal
• Psychiatry
• ENT

26. SUMMARY OF HISTORY
• Complete your history by reviewing what the
patient has told you. Repeat back the important
points so that the patient can correct you if there
are any misunderstandings or errors.
• You should also address what the patient thinks
is wrong with them and what they are
expecting/hoping for from the consultation. A
good acronym for this is ICE – Ideas, Concerns
and Expectations.

27. PATIENT
QUESTIONS/FEEDBACK
During or after taking their history, the patient
may have questions that they want to ask you. It
is very important that you don’t give them any
false information. As such, unless you are
absolutely sure of the answer it is best to say that
you will ask your seniors about this or that you
will go away and get them more information (e.g.
leaflets) about what they are asking. These
questions aren’t necessarily there to test your
knowledge, just that you won’t try and ‘blag it’.

28. When you are happy that you have
all of the information you require,
and the patient has asked any
questions that they may have, you
must thank them for their time and
say that one of the doctors looking
after them will be coming to see
them soon.