Milanote



History Taking EssentialsA good history taking is key to efficient diagnosis and management of ocular health disorders. A great history taking can be performed by following the CLOSER model:C: Control any distractions and potential interruptions that may interfere with attentionL: Lean forward slightly towards the patientO: Maintain an open, nondefensive posture and appear relaxed and at ease with the surroundings.S: Face the patient squarelyE: Maintain Eye contact as appropriateR: Respect the patient’s personal space and position Questions:Tell me why you’ve come to see me today?Do you have a particular problem with your eyes?”Do you see well in the distance?Do you see near objects well?Do you currently wear any vision correction?Do you experience any…?Common symptoms with which patients come for optometry visits and history taking questions:Headaches● Which part of the head?● Both sides or one?● Nature of the pain (sharp, throbbing, dull, cluster andso on)● Associated nausea and vomiting● Associated visual disturbance (migraine as opposed to possible ischemic incident)● Medication being taken for headache● Association with any task, visual or possibly other activityEye pain● Constant or intermittent● Nature of the pain (severe or otherwise)● Associated with eye movementFloaters● Location in view● Size (increasing or decreasing)● Moves with the eye● Solid or web-like● Associations, such as trauma● Associated with flashed/reduced visionFlashes of light● Persistent or transient● Associated with onset of floaters (see previous list)● One or both eyesItching, redness, soreness, tearing, burning, etc.● One or both eyes● Any associations (outdoors, light, season and so on)● Nature of any dischargeDouble vision● Double as opposed to blurred (many patients may be confused by the difference so the practitioner must be careful to help in the distinction)● Monocular or binocular● Vertical or horizontalOther probing questions:History When was it first noticed, had it before?Onset Sudden or gradual?Timing Specifically when does it happen?Causative factors Does anything start or stop it?Duration How long does it last?Frequency Constant or intermittent?Associations Other symptoms with it?Change Getting better or worse?Other Family history? Systemic disorders? Use of any medications? Current treatment? Current health? ................
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