History taking

A history is the story of a patient’s medical disorder. By means of the history, the physician attempts to reconstruct the stages of disease as it has progressed to make a diagnosis and a treatment plan. To elicit a history, the ophthalmic assistant or physician must ask specific questions, linked in an orderly sequence, about the patient’s symptoms. When a specific problem is identified in the patient’s response, further questions are directed to elicit more details. This chapter deals with a method of asking questions so that the patient’s chronicle will be orderly, concise, and complete.

Two types of patients are seen in an ophthalmologist’s office: the patient who desires a routine eye examination combined with a refraction and the patient with symptoms and/or signs of an ocular disorder. However, the person who comes in for a “routine” eye examination may be found to have ocular pathology and the person who comes in with blurred vision, may in fact, be in need of a refraction for glasses. Each patient therefore must be questioned as though one expects to find some ocular disease.

Language issues may cause concern for the ophthalmic assistant, patient, and physician. A translator, including a sign language interpreter, is of utmost importance for getting proper responses. A family member may serve as a translator, however, a trained translator will repeat verbatim what the patient, physician, and assistant say. Other communication challenges may include patients who have had strokes, Alzheimer, Down syndrome, pediatric and hearing-impaired patients. A beginning assistant may need to get help from more experienced personnel. Appendix 8 gives some commonly asked questions in foreign languages.

Organization of a history

The history should be subdivided to maintain organization. Many charts, especially electronic health record (EHR), have the organization laid out. Regardless of the charting method used, an ophthalmic history should include the following:

  • Chief complaint

  • History of present illness

  • History of past health, including significant medical illnesses

  • Previous eye disorders, including past ocular health

  • Previous surgery, both ophthalmic and general

  • Medications currently used and their duration of use. Include supplements, over-the-counter medications, injections, and inhalants

  • Allergies, include inhalants, contactants, ingestants, medications

  • Family history of ocular and systemic disorders, including diabetes, strabismus, glaucoma, blindness, cancer, unusual refractive errors

  • Myopia/hyperopia

  • Occupation, including type of work and industrial hazards

Although many complaints are strictly ocular in nature, others are a manifestation of poor general health or mental health problems. Occasionally, patients may be taking medication that they do not realize affects the eye and may not reveal this aspect of their history unless specifically asked. For example, a patient may be using a scopolamine patch for motion sickness and inadvertently get some of the medication in their eye, causing the pupil to dilate. Such a patient may consult the ophthalmologist for an enlarged pupil or difficulty seeing at near in that eye.

History procedure

In pursuing a history, the ophthalmic assistant should attempt to be precise, professional, and pertinent. With some patients an inquiry into previous health can result in a long, drawn out saga, with complaints of what went wrong over the course of years. The patient, who may not know what is important and what is irrelevant, must be guided by questions. Frequently, patients will state that they enjoy excellent health but when asked what medications they are taking, will respond that they are taking pills for hypertension, injections for diabetes, and iron for anemia. The patient does not connect a general systemic disorder with an ocular problem, yet all the diseases mentioned have serious consequences within the eye.

The ophthalmic assistant should be aware of his or her position to receive privileged confidential information. The covenant that binds the patient and physician and allows private information to be transferred from one to the other also applies to the ophthalmic assistant, who works as an extension of the physician. Patients can be frank in discussing their ailments only when they feel confident that complaints are being aired for diagnostic reasons, not for public consumption. Information garnered during a history should not be revealed to one’s family, friends, or even coworkers. All healthcare workers are subject to the Health Insurance Portability and Accountability Act (HIPAA) which sets the standard for protecting sensitive patient data. The patient’s history falls under the category of “protected health information” (PHI) which includes securing the patient’s full name, address, phone numbers, date of birth, social security and Medicare numbers, and driver’s license number. It is important to lock computer screens and using filter screens when computers are in use in an examination room. This is also important when contacting a patient by phone, fax, or email. Every measure must be taken to protect the patient’s identity. There are stiff penalties for HIPAA violations.

The ophthalmic assistant should not refrain from asking a particular question because it appears to be too private or embarrassing. If the history is conducted in a frank and professional manner and the questions are posed with tact and good taste, the patient will reveal even the most private matters. Of course if the patient states they would prefer to discuss some things only with the physician, that is their right. Above all, patients must have confidence in the professional ethics of the person who treat them. If applicable, one should inquire about previous ophthalmologist or optometrist visits and their diagnosis. Again, if the patient is reluctant to divulge this information, one should not pursue.

The assistant should not attempt to interpret or expand a statement made by the patient. It is best to use the patient’s exact words to describe their complaint, leaving it to the physician to interpret or expand upon.

The organization of questions is a prerequisite to completeness and to a program for efficiency. A routine should be established so that each patient is asked the same basic questions, preferably in the same manner. Of course, the dialog will differ as the complaints of the patients differ, but the sameness of the structural questionnaire will give a certain format to the ophthalmic assistant’s approach and provide an excellent source of data for review or research.

Many electronic medical record software programs help to guide the history taking.

A routine that may be followed in careful history taking is described in the following sections.

General information

Included under general information are the essential facts that should appear at the beginning of every chart ( Fig. 7.1 ). These include the patient’s name, address, date of birth, and work, home and mobile telephone numbers. It is also important to note the source of and reason for the referral. If a patient has been referred by a physician or optometrist, a letter to that person is necessary. The patient’s family or primary care physician’s name, even though not the source of referral, should be noted on the chart. At times, the ophthalmologist may detect, through the ocular examination, signs of a general medical condition, such as hypertension or diabetes, and will want to write to the family or primary care physician of these findings despite the fact that a referral was not solicited. For billing purposes, the type of insurance plan and policy number should be recorded. Ophthalmic assistants should have some familiarity insurance plans as in some instances, the history taking, and other chart documentation may have an impact on whether or not the physician or patient receives reimbursement. The ophthalmic assistant should be aware that refractions may or may not be covered by insurance for various reasons. Finally, inquiry should be made into the patient’s place and type of employment.

Fig. 7.1

Typical history.

Chief complaint

The chief complaint constitutes the reason for the visit. In a sentence or two, the ophthalmic assistant should write down the main reason for which the patient has come to the ophthalmologist for advice and help. In this context, the prime question should be direct, simple, and forthright: “What brings you here today?” Many times the patient responds, “That’s what I’m here to find out!” The patient may reply concisely or give a long, rambling account of various symptoms. If the patient cannot provide focused answers on the main issue after repeated questioning, the ophthalmic assistant should record what he or she regards as the most serious problem among the patient’s symptoms. Commonly described chief complaints are pain, loss of vision, eye fatigue , and blurred vision for near . One must then proceed to pin down the specifics of the complaint, such as date of onset, cause, severity, and duration.

History of present illness

After the chief complaint is recorded, the patient should be questioned in greater detail about the main symptoms. These descriptive terms can be summarized using the mnemonic “FOLDARS” which stands for frequency of symptoms, onset, location, duration, associated signs and symptoms, relief, and severity. For example, asking the patient when the symptoms began and how often they noticed them, as well as if the symptoms come and go or are continuous. Was the patient doing anything that seemed to bring on the symptoms and have they taken any medications or used any items to relieve the symptoms. If the patient is describing pain, use the pain scale of 1 to 10, with 10 being the most severe, and if the pain is interfering with their activities of daily living.

The pertinent points regarding the most common ophthalmic complaints are reviewed in Table 7.1 to aid the ophthalmic assistant in evaluating symptoms and possible causes.

Table 7.1

Ocular symptoms and their possible causes

Symptom Possible causes
Symptoms indicating urgency
Pain in the eye

  • Chemical burn

  • Flash burn to cornea

  • Keratitis

  • Glaucoma

  • Iritis

  • Temporal arteritis

  • Retrobulbar neuritis

Sudden loss of vision

  • Macular degeneration

  • Retinal artery occlusion

  • Retinal detachment

  • Retinal vein occlusion

  • Retrobulbar neuritis

Transient loss of vision

  • Carotid artery disease

  • Migraine

  • Papilledema

  • Severe hypertension


  • Myasthenia gravis

  • Thyroid disorders

  • Diabetes

  • Third nerve palsy from any cause


  • Third nerve palsy

  • Diabetes

  • Myasthenia gravis

Flashes of light

  • Retinal detachment


  • Blow-out fracture of orbit

  • Hyphema

Symptoms requiring prompt attention
Discharge and matting of lids in morning Conjunctivitis
Red eye Any external disease of eye
Swelling of lids

  • Bilateral blepharoconjunctivitis

  • Acute allergies

  • Thyroid disease

Halos around lights

  • Angle-closure glaucoma

  • Cataracts

Blurred vision in the elderly

  • Macular degeneration

  • Cataracts

  • Ischemic optic neuropathy

Persistent tearing in one eye

  • Dacryocystitis

  • Blocked tear duct

  • Entropion, ectropion

  • Trichiasis

  • Chalazion

  • Bell’s palsy

Enlarging nodule on lid Basal cell carcinoma
Foreign body sensation

  • Corneal foreign body

  • Corneal abrasion

  • Herpes simplex keratitis

Significant symptoms that should be seen as soon as possible
Gritty feeling

  • Dry eye syndrome from any cause

  • Conjunctivitis

  • Ocular irritation: dust, wind, ultraviolet lights


  • Often tension

  • Hypertension

  • Brain tumor

  • Migraine, cluster headaches, etc.

Blurred distance vision in adult

  • Diabetes

  • Cataract

  • Macular edema

Spots before eye

  • Retinal tear

  • Vitreous detachment

Pain behind eye

  • Sinus disease

  • Thyroid disorders

  • Orbital tumor (rare)

  • Aneurysm of the carotid artery (rare)

Eruption on skin

  • Atopic allergy

  • Seborrhea

  • Herpes zoster

  • Drug reaction

Loss of vision

Very few patients will state that they have lost vision, unless, of course, they have become blind because of a serious ocular disease or accident. Most patients complain of blurred vision and state this problem in terms of a limitation of function, such as, a decrease in ability to read at near. Blurred vision may have many causes and assume different forms.

Blurred vision secondary to an error of refraction

Hazy, foggy, or blurred vision, if it occurs at a particular distance, usually indicates a refraction error. The myope cannot see in the distance and the hyperope may have difficulty at near. It is the patient with astigmatism who has difficulty seeing both in the distance and at close range. Even with astigmatism, however, poor visual acuity is not evenly distributed, inasmuch as this type of patient will generally see better at close range because of the magnification afforded by proximity. Most patients with refractive errors have a specific visual disability limited to specific activities.

Blurred vision for close work

A patient whose vision is blurred for close work is usually a presbyope and may complain of an inability to read a menu, see their cell phone screen, work on their computer, or read the stock market report.

Blurred vision for distance work

In this instance, the patient is not apt to be a young adult for whom a fresh diagnosis of myopia is about to be made. The patient who is in school most often will complain of inability to see the PowerPoint screen, whiteboard, or blackboard. The patient who drives an automobile will state that road signs appear to be fuzzy, especially at dusk. Occasionally, a patient will recognize this problem by noting that the television set appears fuzzy only to him or her. With regard to television, mothers often become very alarmed when their children sit close to the television screen. This is not usually a symptom of myopia because children like sitting close to the screen for two reasons. First, they enjoy the magnification because big things are easier to view and second, the closer they are to the screen, the greater is their sense of involvement with the story being told.

Blurred vision secondary to organic disease

The patient with organic disease has difficulty seeing things at all times regardless of the activity. The patient who has a cataract or macular degeneration will be limited in both distance (driving) and at near (reading). The patient with a cataract sees as though looking through a frosted glass window and the patient with macular disease finds things missing when looking straight ahead and so must look at them askew.

Loss of central vision

With loss of central vision patients discover that they are unable to see clearly straight ahead but that they have retained peripheral vision ( Fig. 7.2 ). When looking at a face, they may state that the face appears gray or indistinct, whereas the background around the face appears to be clearer. Such a patient commonly sees better in dim illumination. The visual acuity in the affected eye is usually poor. This symptom, if sudden in onset, usually means a disorder of the macula or the optic nerve. If a patient describes a new loss or change in central visual acuity, most physicians will want the assistant to performing an Amsler Grid test (see Ch. 18 ) and color vision testing (see Ch. 8 ).

Fig. 7.2

(A) The road as it appears to a person with normal central and peripheral fields of vision. (B) Loss of central field. The central field of vision is indistinct, whereas the peripheral field of vision remains clear.

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Jun 26, 2022 | Posted by in OPHTHALMOLOGY | Comments Off on History taking

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