Taking a thorough case history is one of the very most important parts of your entire examination. It is a time for you to just sit down and talk to your patient and formulate a picture of the patient’s overall health status. You’ll inquire about their medical conditions, medications, and family history to help determine risk factors for certain conditions.
You’ll also learn about their previous ocular conditions and their history with glasses and/or contact lens wear. All of this information will be extremely helpful when working through their chief complaint and history of present illness to come up with some possible diagnoses which will also aid in guiding your examination.
If you take the time to obtain a thorough case history, you’ll often find that you will be able to have a pretty good idea of your diagnosis for the patient just based on your initial conversation, before you even start to examine them! We’ve come up with a few tips to help you take the best case history possible!
1. Make your Patient Feel Comfortable
Before you dig right in to asking your patient about their personal medical history, take a minute to properly introduce yourself, ask how they are doing today, and find at least one thing to talk about to get them engaged in conversation with you. If it’s Friday, ask about any plans over the weekend. If there’s a big sporting event coming up, ask them if they are planning on watching.
If you notice their cute shoes, let them know and ask where they got them. This little bit of conversation in the beginning will loosen both of you up and help the patient feel more comfortable with you. When they feel more comfortable, they are more likely to open up and share more information with you that can be very valuable.
2. Elicit a Succinct Chief Complaint
The chief complaint should be a single concise sentence explaining the reason for the patient presenting to your office for their visit. This should be in the patient’s own words. For example: “Mrs. Jones presents to the office today stating that she has a sudden onset of blurred vision in her right eye.”
You’ll often find that although this may seem to be an easy task, some patients will go off on many tangents and start giving you so much information that it can be difficult to process. Politely interrupt them if needed and get them back on track to the main reason that they are sitting in your chair.
3. History of Present Illness
Once you have your chief complaint, now it’s time to dive in to more questions in order to obtain more information. Think of this as a detailed interview prompted by the reason for their visit. A lot of students are taught the mnemonic FOLDARS or OLDFART to help guide them through the necessary questions to ask their patients to formulate a good understanding of their issue. However, don’t feel like those are the only questions you have to ask the patient! Depending on the information they give you, feel free to go off script to dig deeper where necessary.
Based on the example chief complaint above, here is what an HPI should look like:
-Onset :When did the patient's problem occur?
"Mrs. Jones, when did you first notice the blurred vision?"
-Location :Is the patient noticing symptoms in one or both eyes? At distance and/or near?
"Mrs. Jones, I know you mentioned that the blurred vision occurred in the right eye, but have you also noticed any changes in your left eye?" "Is the blurred vision at all ranges, or just one distance?"
-Duration :Have the patient's symptoms been consistent since onset?
"Mrs. Jones, has the blurred vision in your right eye been constant since you first noticed the symptoms? Or does it come and go?"
- Frequency :Is this the only occurrence of these symptoms, or have they happened before?
"Mrs. Jones, is this the only time something like this has occurred? If so, how often does this happen, and when was the last occurrence?"
- Associated Symptoms : Are there any other symptoms that could be related to the chief complaint?
"Mrs. Jones, is there anything else that you can think of that could be related to your symptoms? Any flashes of light or new floaters? Any pain, irritation, or discharge? Have you been sick recently, or around anyone who was ill?"
- Relieving Factors : Is there anything that the patient has tried that has improved his/her symptoms?
"Mrs. Jones, have you taken any medications or eye drops to try to help relieve your symptoms? Did anything work?"
- Severity: How bad are the patient's symptoms?
"Mrs. Jones, on a scale of 1-10, 10 being the worst, how would you rate the blurred vision in your right eye?"
4. Ask Direct Medical Questions
When going through the patient’s medical history, ask specific health questions rather than general medical questions. For example: “Do you have any history of hypertension, diabetes, or high cholesterol?” Rather than “Do you have any medical conditions?” You’ll find that patients are more likely to give you more information when asking pointed questions.
You may also be surprised at how many patients may say “no” when asked about medical conditions, but then tell you that they are taking medications that are clearly for blood pressure control, or diabetes. If that happens, go back and ask about the medical history again. It’s amazing how many people don’t think they have a condition anymore once it is controlled with medication!
5. Educate Your Patients
Patients often won’t understand why you, as an eye doctor, are asking about their medical conditions and systemic medications. They may not realize the effect that certain conditions and drugs can have on the eyes, so before you start asking about their personal medical history, take a second to educate them on why it is important for you to know these things.
This is another way to help them feel more comfortable with you and what you are doing, again, making them more likely to open up and provide you with valuable information that can help you provide them with a better examination and treatment plan.