1-cr History Taking.docx

CLINICAL REFRACTION – I

Clinical Refraction is the most important branch of modern Optometry which includes the clinical application of various methods of eye examinations and management of visual anomalies if any. Vision is more than Eyesight.

Research indicate that at least 80 % of learning occurs through the visual pathway. If the patient has a visual acuity of around 20/20 or 6/6, which is universally recognized and the patient was assumed to have good vision and no visual problem.

Case History Clinical Case History is a very essential process in the investigation of any clinical condition by taking a history (H/O) before examination start. The clinical history has the diagnostic value of the data obtained.

To take a good history, skill, accuracy and patience of the clinician are require. Difficulties arise when the patient’s intellectual level is low and he or she is unable to grasp the meaning of the questions, but experience soon teaches the doctor to formulate his questions in a manner suitable to each patient’s intelligence.

History Taking Procedure : This procedure is generally conducted by asking the patient – On previous general treatment and general condition. Has the patient suffered from any general diseases ? Has the patient suffered from any general diseases in the past ? Enquire about the present general health status. It is highly important to establish the general condition of the patient. Which systemic diseases he or she has had in the past or is suffering from at that time.

Recording style :

H/O : History Of Examples – H/O Diabetes Mellitus (DM) H/O Hypertension H/O Dandruff H/O Arteriosclerosis H/O Hypothyroidism H/O Long standing systemic steroid treatment On previous ocular condition or the patient suffered from any ocular diseases in the past

Examples. – H/O : Glaucoma On Glass or Spectacle –

Examples – H/O : Has a spectacle OD : OS: H/O : Glasses Social History ( living condition) : S/H

Example – S/H : Socio-economically poor

Family History should be taken because , sometimes, it is important in establising the diagnosis.

Family History : F/H Examples – F/H : Myopia F/H : Hypertension F/H : Diabetes Mellitus F/H : Retinitis Pigmentosa Medical History : M/H

Examples – M/H : Has taken systemic steroid since about 2 yrs. Past History : PH or P/H Psychiatric History : PsyH

The Complaint : The complaint is the patient’s description of his present Symptoms. The complaint is most advisable to allow the patient to express his or her symptoms in his or her own words and give him ample opportunity to reveal all the symptoms. The intelligent patient may, in a few minutes, give a history or complain but comparatively less intelligent patient are unable to describe the nature of their history or complaint without help from the examiner in the from of simple questions. Complaint :

C/O.

a) Chief Complaints Example -

C/O : Poor DV & NV b) Secondary Complaints

Example C/O : Recurrent Itching in BE

About vision : Examples C/O : Poor NV only C/O : Sudden loss of vision in RE C/O : Gradual loss of vision

About pain or ache : Examples C/O : Headache C/O : Eye-ache in RE or LE or BE ----------------