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    Ophthalmology History Sheet

    Uploaded by

    Israa Alaa
    The document provides guidance on taking an ophthalmology patient history. It outlines exploring the chief complaint using the OCDPQRSTUVAAA format and following up on positive responses. The history should also cover past medical/surgical/eye history, family history, social history, medications, allergies and a review of systems. The provider is advised to empathize with the patient, ask open-ended questions, and clarify responses to fully understand the patient's ocular issues and concerns.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Ophthalmology History Sheet

    Uploaded by

    Israa Alaa
    348 views3 pages
    The document provides guidance on taking an ophthalmology patient history. It outlines exploring the chief complaint using the OCDPQRSTUVAAA format and following up on positive responses. The history should also cover past medical/surgical/eye history, family history, social history, medications, allergies and a review of systems. The provider is advised to empathize with the patient, ask open-ended questions, and clarify responses to fully understand the patient's ocular issues and concerns.

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    Ophthalmology History Sheet

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    The document provides guidance on taking an ophthalmology patient history. It outlines exploring the chief complaint using the OCDPQRSTUVAAA format and following up on positive responses. The history should also cover past medical/surgical/eye history, family history, social history, medications, allergies and a review of systems. The provider is advised to empathize with the patient, ask open-ended questions, and clarify responses to fully understand the patient's ocular issues and concerns.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    348 views3 pages

    Ophthalmology History Sheet

    Uploaded by

    Israa Alaa
    The document provides guidance on taking an ophthalmology patient history. It outlines exploring the chief complaint using the OCDPQRSTUVAAA format and following up on positive responses. The history should also cover past medical/surgical/eye history, family history, social history, medications, allergies and a review of systems. The provider is advised to empathize with the patient, ask open-ended questions, and clarify responses to fully understand the patient's ocular issues and concerns.

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    Ophthalmology history sheet

    • Introduce yourself and your role


    • Confirm the patient’s name and date of birth
    • Gain consent to take a history / exam / etc.
    Show empathy, sit in at level with the patient, make eye-contact, listen carefully,
    do not interrupt, encourage the patient to clarify more, establish a good rapport,
    summarize at intervals
    • Start with an open-ended question of the presenting complaint
    “What brings you in today?” or "What troubles you?”

    • Explore the patient’s complaint in the OCDPQRSTUVAAA format


    O: Onset: Did it start suddenly / gradually?
    C: Course: Is it getting better or worse or the same?
    D: Duration: When did it start?
    P: Pain: Is there any pain?
    Q: quality: What is the type?
    R: radiation: Does it radiate anywhere (if pain)
    S: site and severity: Where is it located and how severe is it on a scale of 1-10.
    T: Timing: Is it worse in the day / night? Are there days better than others?
    U: How is this affecting U?
    V: Déjà vu: has this happened before?
    A: Alleviating factors: What makes it better?
    A: Aggravating factors: What makes it worse?
    A: Associated symptoms: ask an open-ended question first then ask specifically
    about other symptoms: pain, loss of vision, redness, discharge, photophobia,
    blurry vision, nausea, vomiting, itching, swelling, tenderness and dry eyes.
    If Positive – further exploration as follows
    • Pain: OCDPQRSTUVAAA
    • Loss of vision: peripheral / central, unitlateral/bilateral, complete/incomoplete,
    permenant/ transient, + sudden/gradual, distortion in the shapes of things, double
    vision, distance/near vision/ both, flashing lights, floaters, haloes, like a black curtain?
    • Redness: Location, localized/diffuse?
    • Discharge: Watery / mucopurulent, one or both eyes, eyelashes sticky in the morning?
    • Photophobia: Does it hurt to look in bright light? In one or both eyes?
    • Blurry vision: Do you have blurry vision? In one or both eyes?
    • Dry eyes: Do your eyes feel dry, gritty sensation? In one /both eyes?
    • Ask about itching: Do you need to rub your eyes? In one or both eyes?
    • Swelling: Did you notice any swelling in your eyes? In one /both eyes? Worse in the
    morning or present all day?
    • Tenderness: Does it hurt when you touch it?
    • Trauma: Ask about trauma and ask what happened, is there a foreign body in the eye?

    ICE:
    Explore ideas, concerns and expectations
    What do you think is wrong with your eyes?
    Is there anything that scares or concerns you?

    What do you expect from us today?

    Past Medical & Surgical History:


    • Previous eye complaint
    • Any chronic medical conditions: diabetes mellitus, hypertension, atopy, autoimmune
    disease
    • Any previous ocular trauma
    • Any previous ocular operation
    • Contact lens use

    Family History
    • Family history of glaucoma, retinal detachment
    • Family history of diabetes, hypertension
    • Family history of rheumatic or autoimmune disease
    Social History:
    Ask in detail especially if the patient is suffering from visual loss

    • Housing: ask about safety, risk of falling/ sliding, if needs to use the stairs: any help
    available, any sharp edges in case of falling, availability of carpets to prevent falling,
    smoke detectors in case of fire, etc.
    • Social support: does the patient live alone or with other family members
    • Driving: especially if there are problems with vision
    • Function: Is the patient able to carry out his daily activities on his own?
    • Occupation, hobbies
    • Smoking, alcohol or drug abuse

    Medications:
    • Prescribed and over the counter medications
    • Oral contraceptive pills (if female)
    • Herbal remedies

    Allergies:
    • Allergies to medication or other allergens

    ROS (Review of Systems)


    Summarize the main points
    Ask if the patient has any questions
    Thank the patient

    References
    • Dr Sahib Tuteja and Dr Andrew Blaikie·History taking·March 27, 2021·Last updated:September 27 (2023) Ophthalmic history taking -
    OSCE guide, Geeky Medics. Available at: https://geekymedics.com/ophthalmic-history-taking-osce-guide/ (Accessed: 02 November
    2023).
    • NAC OSCE: A comprehensive review (2011). CanadaPrep.

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