[ODCOP1] Case History Taking

Case History

• The first and most important test you perform - It tells you which tests of visual function are actually needed for this patient (e.g., unexplained headache → visual field testing)

• A thorough (BLANK) can narrow the diagnosis before you even touch an instrument

Patient demographics & reason for visit

Chief Complaint and Associated Complaint

History of Present Illness

Past Ocular History

Past Medical History

Family History

Medications & Allergies

Social/Occupational History

Parts of a Complete Case History

Demographics & Reason for Visit

• Name, age, sex, occupation

• Date and reason for today's visit (routine check-up vs. specific complaint)

• Last eye exam (LEE) date and outcome

Chief Complaint (CC)

• The patient's own words describing why they came in

• Record duration, which eye(s), and whether it's new or recurring

• Avoid leading questions — let the patient describe it first

• Stress: write the CC in the patient's own language, not your clinical interpretation.

• Associated Complaint

History of Present Illness (HPI)

Use the mnemonic OLDCARTS:

• Onset

• Location

• Duration

• Character

• Aggravating/Alleviating factors

• Radiation

• Timing

• Severity

OLDCARTS (example)

• Blurred vision:

  • One eye or both?

  • Sudden or gradual?

  • Near, far, or both?

  • Headache: Location?

  • Time of day?

  • Associated with near work?

  • Eye pain:

    • Sharp or dull?

      • Constant or intermittent?

      • Photophobia present?

Past Ocular History (POHx)

• Previous eye conditions, injuries, surgeries

• History of amblyopia, strabismus, or patching as a child

• Previous glasses/contact lens wear

• Eye drops or ocular medications

Past Medical History (PMHx)

• Systemic conditions with ocular significance: diabetes, hypertension, autoimmune disease, thyroid disorders

• Past surgeries and hospitalizations

• Current systemic medications

• Note: some systemic drugs (e.g., steroids) directly cause ocular side effects — preview for later units.

Family History (FOHx/FMHx)

• Glaucoma, AMD, retinal detachment, strabismus, amblyopia — ask about parents, siblings, grandparents

• Diabetes, hypertension (hereditary risk factors)

• A positive family history raises clinical suspicion even without symptoms

• A positive family history of glaucoma, for example, justifies closer IOP/visual field monitoring even in an asymptomatic patient.

Medication & Allergies

• List all current medications (ophthalmic AND systemic)

• Include over-the-counter drugs and supplements

• Document drug, food, and environmental allergies with reaction type

Social & Occupational History

• Occupation and visual demands (computer work, driving, fine detail work)

• UV/hazardous exposure, smoking

• Contact lens wear habits (type, schedule, compliance)

• Hobbies/sports requiring specific visual needs

• Ties directly into patient-specific recommendations later in the course.

Clinical Significance: History Guides Testing

• Symptoms of blurred vision → check visual acuity & contrast sensitivity

• Unexplained headache, scotoma, or neuro symptoms → visual field testing indicated

• Colour vision complaints → formal colour vision testing

• Family history of glaucoma → prioritize visual field & IOP monitoring

• Core takeaway: the case history directs which of the tests you'll learn this semester are necessary for a given patient.

Red Flags

• Sudden vision loss

• Moderate-to-severe eye pain

• Flashes/floaters with vision changes

• Trauma history

• Symptoms suggesting neurological involvement (diplopia, dizziness, limb tingling)

• These warrant prompt and careful work-up — don't let a patient downplay them.

Case History Analysis

• Once all verbal information is collected, the clinician should have a list of tentative diagnoses in mind for each identified problem. T

• he rest of the eye examination is then directed toward confirming or ruling out each one.

• The case history is not just documentation — it is the beginning of clinical reasoning.

LOFTSEA

• An alternative/complementary mnemonic to OLDCARTS

Location / laterality

Onset

Frequency / occurrence

Type / severity

Self-treatment and its effectivity

Effect on the patient

Associated Factors

LOFTSEA

Interpreting the Chief Complaint

• Blurred distance vision (gradual, bilateral) → likely ametropia; check VA and refraction

• Blurred near vision (over 40, gradual) → likely presbyopia; check near VA and reading add

• Headaches after near work (afternoon, dull, frontal) → possible decompensated heterophoria or uncorrected hyperopia

• Sudden, unilateral vision loss → urgent; red flag — rule out optic neuritis, CRVO, retinal detachment

Interpreting Medical & Ocular History

• Diabetes (especially >10 years, poorly controlled) → specifically look for signs of diabetic retinopathy; consider dilated fundus exam

• Hypertension on beta-blockers → beta-blockers can cause dry eye; correlate with any ocular surface complaints

• Oral corticosteroids (long-term) → associated with posterior subcapsular cataract formation History of strabismus surgery / amblyopia → document carefully; affects baseline VA expectations

Interpreting Family History

• Family history of glaucoma → prioritize IOP, optic nerve head assessment, visual field screening — even in a young, asymptomatic patient

• Family history of AMD → macular assessment becomes higher priority

• Family history of strabismus or amblyopia → especially important in pediatric cases; screen carefully for these even without complaint

• Family history of diabetes / hypertension → systemic risk factor; note for long-term monitoring

Recording the Case History Correctly

• Use standard abbreviations — personal abbreviations create confusion and legal risk.

• Key rules:

  • Record both positive and negative responses (if not recorded, it was legally not asked) --

  • Use the patient's own words in quotation marks where helpful

  • Follow the SOAP format: Subjective (case history) → Objective (test results) → Assessment → Plan

Subjective

Objective

Assessment

Plan

SOAP

Subjective

• Everything the patient tells you → the case history (CC, HPI, POHx, PMHx, FOH, medications, social history)

• case history

Objective

• Everything you measure or observe → test results, VA findings, slit-lamp findings, etc.

• test results

Assessment

• Your clinical interpretation → tentative diagnoses, differential diagnoses, grading of findings

Plan

• What you will do next → additional tests, referral, spectacle prescription, follow-up schedule

• "The S and O provide the data; the A and P close the loop back to the patient's complaint."