Case History - Optometric Exam Lecture Fall 2025

to obtain the necessary information to effectively lead to the appropriate diagnosis

What is the purpose of the case history?

S = subjective

O = objective

A = assessment

P = plan

What is the SOAP format in the case history?

info that you get from the patient (symptoms)

What is subjective info?

the info you get from testing & findings from these tests

What is objective info?

Combines the subjective and objective info. Used to make a diagnosis

What does the assessment combine? What does the assessment help us make?

no -- you can always go back to this portion if a patients gives up more info later in the exam

Does the case history ever end during an eye exam?

No -- and you also need to document the pertinent negatives to the case

If you do not document a finding, legally, did you ever ask it?

rapport

Case history helps develop patient ______

no -- you should ask open ended and close ended questions

Should you ask leading questions during a case history?

Mrs. Smith/Mr. Smith

How should you call adult patients from the waiting room?

introduce yourself and engage in small talk

What should you do as you are walking back to the exam room from the waiting room with the patient?

NEVER -- wait until you are in the exam room before soliciting personal medical information

Should you discuss patient information in the hallway?

at eye level and at an appropriate distance

How should you sit with a patient in the exam room?

-chief complaint

-history of present illness

-last eye exam and last physical exam

-review of systems

-medical history and ocular history

-medication and med allergies

-family medical history and family ocular history

-social history

-general observations

What are the 9 parts of a complete medical history?

chief complaint

Why the patient came in today

short phrase

A chief complaint should be a _______ documented in the patient's words

with an open ended question

**"What brings you in today Mrs. Smith"

How should you begin a chief complaint?

wait to document a chief complaint until you determine if there is really something else that concerns them

What happens if the patient tells you that they are "just here for routine eye exam" during their chief complaint?

symptoms that they request be addressed

What is a patient driven chief complaint?

previous diagnosis warrants further evaluation or ongoing care

What is a doctor driven chief complaint?

#1

The chief complaint should correspond to the ______ diagnosis in the plan tab

-blurry vision

-dry eyes

-red eyes

-eye pain

-eyestrain

-HAs

-floaters

What are some examples of a chief complaint?

more detailed questions about the chief complaint

What is the HPI -- History of Present Illness?

-location

-quality

-severity

-duration

-timing

-context

-signs/symptoms

-relieving factors

-aggravating factors

-negative symptoms

What are the HPI categories?

no -- only ask the relevant questions

Will every HPI question apply to every chief complaint?

Where is the problem?

HPI Categories

What question should you ask the patient for the location category of the HPI?

Please describe the pain to me. It is a dull ache, radiating or throbbing? Would you say the pain is worsening, improving or stable?

HPI Categories

What should you ask the patient for the quality category of the HPI?

How would you rate your pain on a scale of 1-10. When was the best the pain was? What was the worst the pain was? What is the pain today?

HPI Categories

What question(s) should you ask the patient for the severity category of the HPI?

How long has this been going on?

HPI Categories

What question(s) should you ask the patient for the duration category of the HPI?

When does this happen during the day?

HPI Categories

What question(s) should you ask the patient for the timing category of the HPI?

What are you doing when this happens?

(driving, wearing glasses, working on computer)

HPI Categories

What question(s) should you ask the patient for the context category of the HPI?

Is there anything else going on that you think may be related to this?

HPI Categories

What question(s) should you ask the patient for the signs/symptoms category of the HPI?

yes

Can a patient have more than 1 chief complaint?

check the primary box

What should you do in the HPI section next to the chief complaint?

yes

Do you need to complete an HPI for any additional complaint?

inquire about common complaints such as blur, itchiness, dryness to see if a complaint is elicited

If no chief complaint is offered from the patient, what should your next steps be?

Vision and Eye Health Evaluation

If no chief complaint is elicited after inquiring about common complaints, what should you write in the chief complaint section?

yes

Do you still need to fill out an HPI even if the chief complaint is "Vision and Eye Health Evaluation".

-date

-practitioners name

-were they monitoring you for any issues?

What questions should you ask regarding the patient's last eye exam?

-date

-practitioners name

-were they monitoring you for any issues?

What questions should you ask regarding the patient's last physical exam?

review of systems

What section should you complete after receiving info about last eye and physical exam?

no -- use lay terms

Should you use medical terms when completing a review of systems?

open ended questions

What type of questions should you ask at the beginning of the review of systems section?

yes -- but you do not need to go in order. Let the patient response to your initial open-ended question drive the conversation.

Do you have to cover each category in the review of systems section?

"Do you have any heart issues like high blood pressure or high cholesterol?"

For "cardiovascular" in the review of systems section, what is a good open ended question to ask the patient?

Do you have any issues with your ears, nose, or throat? Things such as sinus problems or any similar issues?

For "Ear, Nose, Mouth, Throat" in the review of systems section, what is a good open ended question to ask the patient?

Do you have any breathing problems? Do you have any history of asthma or sleep apnea?

For "Respiratory" in the review of systems section, what is a good open ended question to ask the patient?

Do you have any issues with you stomach, like heartburn or nausea?

For "Gastrointestinal" in the review of systems section, what is a good open ended question to ask the patient?

Do you have any problems with your kidneys or bladder?

For "Genitourinary" in the review of systems section, what is a good open ended question to ask the patient?

Do you have any muscle or joint problems, like arthritis?

For "Musculoskeletal" in the review of systems section, what is a good open ended question to ask the patient?

Do you have any issues with your skin?

For "Integumentary" in the review of systems section, what is a good open ended question to ask the patient?

Are you bothered by headaches or other neurological problems?

For "Neurological" in the review of systems section, what is a good open ended question to ask the patient?

Do you have any problems with anxiety or depression?

For "Psychiatric" in the review of systems section, what is a good open ended question to ask the patient?

Do you have any diabetes or thyroid issues? Any hormone imbalances?

For "Endocrine" in the review of systems section, what is a good open ended question to ask the patient?

Do you have any blood disorders, like anemia?

For "Hematologic/Lymphatic" in the review of systems section, what is a good open ended question to ask the patient?

Have you ever been diagnosed with any autoimmune disorders? Do you have any allergies?

For "Allergic/Immunologic" in the review of systems section, what is a good open ended question to ask the patient?

-everything from ROS

-PLUS any former medical problems

What will be put in the past medical history section of the case history?

-diabetes

-high blood pressure

What should you specifically ask about in the past medical history section?

-any other significant medical issues?

-any other major surgeries?

-other significant health concerns?

What other things should be asked in the past medical history section of the case history?

"Have you or your eye doctor ever had a concern about the health of your eyes or the status of your vision?"

How to start the "past ocular history" section?

1) things the patient perceives

2) things that happen to the eyes

3) diseases & conditions of the eyes

What are the three groups of questions to ask your patient regarding past ocular history?

-Have you ever had double vision?

-Do you see flashing lights or floating spots in your vision?

-Do you have eyestrain?

-Do you notice your eyes being dry or itchy?

What are some things that the patient PERCEIVES that can be included in the past ocular history section of the case history?

-Have you ever had any eye injuries?

-Have you ever had any eye infections?

-Have you ever had any eye surgeries, including LASIK?

What are some things that could HAPPEN to the patient that can be included in the past ocular history section of the case history?

-Have you ever been diagnosed with glaucoma or catatacts?

-Have you ever been diagnosed with any retinal diseases?

-Have you ever been diagnosed with an eye turn or have been treated with patching?

What are some things that could be asked about in the DISEASES AND CONDITIONS part of the past ocular history section of the case history?

-systemic

-ocular

-vitamins/supplements

**also obtain dosages

What types of medications should be asked about in the case history?

-systemic

-ocular

-environmental/food

**ask about the type of reaction

What types of allergies should be asked about in the case history?

blood relatives only

Questions about the patients family medical & ocular history pertain to who?

-alcohol use

-drug use

-tobacco use

If a patient is over 18+, you must ask about what for the social history section of the case history?

"Post Tobacco Use (Z72.0) to Dx List"

If the patient is a current smoker, what button needs to be hit?

No, it also pertains to occupation, hobbies, & sports

Is social history just about alcohol, tobacco, and drug use?

body features (normal vs abnormal)

appearance (normal vs abnormal)

What should you document under the general medical observation tab?

oriented is normal

What is a normal documentation for the patient orientation to time, place, & person?

appropriate is normal

What is a normal documentation for the patient mood and affect?

medical and ocular history for both the patient and the family

When doing a case history for an established patient, what will carry forward from the previous layout?

yes -- but you must make sure it is still current

Can you forward the ROS from the last visit when doing the case history for an established patient?

no -- these exams may focus on the chief complaint and the HPI

Do all exams warrant a complete case history?