What is Case History?

By Eyecare NG

Your case history is an account of your health condition gathered by your eye doctor by asking you (or people aware of your condition) specific questions, with the aim of obtaining information that will be useful for your eye examination, diagnosis and care.

Every comprehensive eye examination starts with a detailed case history. To ensure that you provide all the information that will help your eye doctor understand your condition and take appropriate decisions and actions with respect to your eye exam, diagnosis and care, it is recommended that you compile your history before visiting your doctor.

The following information may be included in a detailed case history;

Chief Complaint

This is the primary problem that made you decide to visit your eye doctor.  Questions about your main problem along with symptoms and associated factors are usually asked at the beginning of history taking.  Some of the questions your doctor may ask include:

  • What brings you here today?
  • How long have you been experiencing this problem or when did you start experiencing it?
  • Which eye is affected?
  • Are there other symptoms associated with it?
  • What relieves you of the symptom and what makes it worse (relieving and aggravating factors)?
  • Have you experienced the symptom(s) before? When? What did you do then?

Ocular History

While taking your ocular history, your doctor focuses on obtaining information on your eye health history including previous eye examinations, diagnosis and care given. It also includes information on your present lens prescriptions and medications (if any). Some of the questions that may be asked include:

  • When was your last eye examination? Where was it done? Why was it done?
  • Do you wear glasses? If yes, since when? When was the present glasses prescribed? What is your prescription?
  • Have you ever had crossed eyes? Have you ever worn an eye patch? Have you been treated for amblyopia?
  • Have you had an eye surgery done before? If yes, what kind of surgery? When? Where? Which eye?
  • Have you had any form of injury to your eye(s)? If yes, when? What kind of injury? Which eye? What was done about it?
  • Are you on any medication(s) now? What was it prescribed for and by whom? How long have you been taking the medication?

Medical History

The eye doctor will want to know any medical history you may have. This is important because many medical conditions have eye symptoms. Also, some eye treatment may not be suitable for persons with certain medical conditions. Therefore, knowledge of your medical history is necessary for proper diagnosis and care. Some questions that may be asked include:

  • Do have any medical condition?
  • Have you been diagnosed with any of these – hypertension, diabetes, asthma, arthritis, dental problem, sickle cell anaemia and epigastric ulcer?
  • Are you on any medication for this? If yes, what is the name of the medication?

For children, the doctor may ask questions about the mother’s health when she was pregnant with the baby, the method of delivery (forced delivery, spontaneous or Caesarean section), APGAR score, vaccination history and other information that may be useful for the examination, diagnosis and treatment of the child’s eye condition.

Family History

Family eye health history is important because some eye diseases are hereditary. Many of them either do not show symptoms early or their symptoms are so subtle that you may not be aware until some damage has been done. Knowledge of your family health history may prompt more checks or careful monitoring of your eyes to ensure that hereditary diseases are detected early.  In taking your family history, you are asked questions relating to the ocular and medical history of your parents, siblings and other relations. The doctor may want to know whether any of your family members had or has been diagnosed with glaucoma, retinal detachment, cataracts, diabetes, hypertension, squint and other hereditary diseases.  He may also ask if any of them was or is blind.

Known Allergies

Knowledge of the allergies you have is necessary especially with respect to your eye examination and treatment. Ensure you tell your doctor the drugs and other substances and materials you are allergic to. This is to avoid a situation where you are prescribed medications that may cause allergic reactions.

Occupation and Hobbies

The symptoms you are experiencing may be related to your occupation or hobbies. Therefore, it is important to share information on your occupation and hobbies with your doctor. In addition to helping diagnosis, treatment given to you can be tailored to suit your work and recreational activities.