Transcript Slide 1
History Taking And Recording Of Ophthalmic Cases Chairperson : Prof. Gautam Bhaduri Speaker : Kumar Saurabh Technique How to ask? Open enquiries Closed enquiries Clarification Reflection Summary Technique What to ask? Patient particulars Chief compliant(s) History of present illness History of past ocular illness History of ocular surgery/treatment History of systemic diseases including STDs Family history Personal history History of drug intake/addiction Patient particulars Name Address Identity records for future reference Medico legal records and follow up Denotes ethnicity Endemic toxicities viz. Arsenic Denotes the personality Epidemiological data collection Patient particulars Age Children Young adults Middle and older Retinoblastoma Parsplanitis CRAO Rhabdomyosarcoma Central serous retinopathy BRVO Coat’s disease Eale’s disease ION Optic nerve glioma Fuch’s uveitis ARMD Patient particulars Gender Female Male Dysthyroid ophthalmopathy Eale’s disease Chronic dacryocystitis Central serous retinopathy Angle closure glaucoma Coat’s disease Post-JRA uveitis Lacrimal tumours Patient particulars Religion and race Occupation Congenital anomalies in Muslims and Parsi Fungal infection in farmers Trachoma in north Indians Dry eye in computer operators Vitamin A deficiency in under privileged Cataracts in hot furnace workers Presenting complaint Visual complaint Dimness of vision Unilateral or bilateral Duration Mode of onset Diurnal variation Pain or without pain Distortion of images History of coloured halos History of use of glasses History of trauma Dimness of vision Unilateral Bilateral BRVO Senile cataract CSR ARMD Secondary glaucoma Primary glaucoma Unilateral trauma Retinal vasculopathy Dimness of vision Transient Prolonged Senile cataract Amaurosis fugax ARMD Vertebrobasilar artery block Migraine Glaucoma Retinal vasculopathy Dimness of vision Sudden Gradual Optic neuritis Senile cataract CRAO & CRVO ARMD Vitreous hemorrhage Primary open angle glaucoma Retinal detachment Retinal vasculopathy Dimness of vision With pain Without pain Optic neuritis Senile cataract Angle closure glaucoma ARMD Keratitis Central serous retinopathy Anterior uveitis Retinal vasculopathy Dimness of vision With coloured halos With distorted images Congestive phase of ACG Central serous retinopathy Mucopurlent conjunctivitis ARMD Migraine Astigmatism Digoxin, chloroquine intake Cataract Dimness of vision Glasses: What to ask? Frequent change of glasses Duration of use Uncontrolled diabetes mellitus Power of glasses Keratoconus Any frequent change of power Progressive myopia Any refractive surgery in past Open angle glaucoma Dimness of vision Diminished colour vision Diminished central vision Diminished peripheral vision Hereditary Optic neuritis Advanced glaucoma Immature cataract Retrobulbar neuritis Retinitis pigmentosa Optic neuritis Macular pathology Retinal detachment ARMD AION Dimness of vision Diminished night vision Uniocular double vision Binocular double vision Vitamin A deficiency Recent corneal opacity Paralytic strabismus Retinitis pigmentosa High astigmatism Dysthyroid oculopathy Subluxated lens Blow out fracture Iridodialysis Myasthenia gravis Dimness of vision Photophobia Glare Corneal abrasion Immature cataract Interstitial keratitis Large pupil Phlyctenular keratoconjunctivitis Recent aphakia UV light exposure Albinism Non-visual complaint Red eye Without pain With pain Vernal conjunctivitis Infective conjunctivitis Subconjunctival hemorrhage Keratitis Angular conjunctivitis Iridocyclitis Pterygium Episcleritis & Scleritis Watering and discharge from eyes Watering Discharge Trauma or foreign body Watery: Viral, trachoma Conjunctivitis Mucoid: Allergic Blockage of drainage Purulent: Bacterial Ectropion lower lid Bloody: Trauma, membrane Dryness of eyes Infection Dermatological Others Trachoma SJ syndrome Scleroderma Diphtheria Pemphigoid vulgaris Rheumatoid arthritis Exfoliative dermatitis Sarcoidosis Acid/alkali injury Pain Pain in the eye ball Tenderness in the eye ball Trauma Iritis Iridocyclitis Iridocyclitis Acute angle closure glaucoma Retrobulbar neuritis Herpes zoster ophthalmicus Pain Pain around the eye Pain on eye movement Stye Retrobulbar neuritis Acute dacryocystitis Optic neuritis Herpes zoster Myositis Sinusitis Migraine Drooping of eye lids Age of onset Duration Unilateral or bilateral Diurnal variation Family history History of trauma History of systemic diseases History of surgery Ask for old photographs Bulging of eyes Acute onset: Orbital hemorrhage Subacute: Orbital cellulitis, panophthalmitis Intermittent: Recurrent hemorrhage, varix With dimness of vision: Optic nerve glioma, trauma Without pain: Cavernous haemangioma, lacrimal tumour With pain: Malignant, inflammatory, ruptured dermoid Bulging of eyes Children Adult Orbital cellulitis Thyroid ophthalmopathy Retinoblastoma Lacrimal tumour Rhabdomyosarcoma Cavernous haemangioma Leukemia Malignant melanoma Misalignment of eyes Age of onset Duration Unilateral or bilateral Constant or intermittent Diplopia, vertigo, past pointing Detected by Family history History of surgery Ask for old photographs Floaters Single: Weiss ring Few: Condensation of vitreous collagen Shower of floaters: Vitreous hemorrhage Permanent: All of the above Transient: Migraine Headache Hypermetropia, astigmatism Angle closure glaucoma Uveitis Convergence insufficiency Accommodative spasm Herpes zoster ophthalmicus Trigeminal neuralgia Giant cell arteritis Keratitis Migraine History of past ocular illness Non-ischemic CRVO Rhegmatogenous retinal detachment History of systemic illness Diabetes mellitus Hypertension AIDS Sarcoidosis Anemia, leukemia Neurofibromatosis Rheumatoid arthritis Family history Retinoblastoma Congenital ptosis Night blindness Colour blindness History of drug intake Type of drug Duration of use Any change in symptom Other side effects Idiosyncrasy, allergy History of drug intake Cataract Optic neuritis Amiodarone Isoniazid Busulphan Ethambutol Corticosteroid, chlorpromazine Streptomycin Retinopathy Dry eye Chloroquine Anticholinergics Chlorpromazine Propranolol Tamoxifen Hydrochlorthiazide History of trauma cases Time, place and circumstance of injury History of accident or assault Events following injury Treatments if any, taken Police reporting Case recording Purpose Method Patient follow up Patient’s details Medico-legal aspects Disease details Academic aspects Classified approach Health insurance Impact on life Thank You!