Melissa Valdellon

The complete case history

When a patient comes in for their comprehensive eye exam, we have a few things we need to address. We need to assess visual status of each eye, binocularity and visual function, and ocular health. How does that translate to in my case history?

I have mentioned before that I have kind of developed a bit of a speech for the beginning part of my exam that helps me hit all the necessary points for a comprehensive eye exam. And if the patient brings up other topics, I re-direct them here and there to make sure we get my main questions asked, which are:

  1. Do you have problems with your vision in the distance or up close?
  2. Do you use glasses for distance or up close?
  3. How old are the glasses you are using?
  4. When was the last time you had your eyes examined?
  5. Do you have any headaches or eyestrain in general?
  6. In general, how do your eyes feel? Do they feel dry, itch, or burn?
  7. What eyedrops do you use?
  8. And how about your general health – do you have diabetes, HTN, or other systemic conditions?
  9. What medicines do you take?
  10. Do you have any allergies to any medications?
  11. Do you have any history of surgeries or injuries to the eyes?
  12. And in the family, does anyone have any eye problems or conditions and how are those conditions being managed?

Of course, depending on the patient’s response, I would go into more or less detail on some of these points. Obviously, I wouldn’t ask about glasses if I actually know this is a child’s first eye exam after failing a vision screening. I would ask a diabetic patient what year they were first diagnosed, what’s the highest and lowest blood sugar reading they’ve had over the past month, their latest HbA1c if they know it, and how closely they’re being monitored by their PCP or endocrinologist. And if it were a patient I have been monitoring for an ocular condition, like glaucoma or macular degeneration, I would follow up about their compliance with eyedrops or supplements and Amsler testing if needed.

And as a reminder, I spread out my questions to the appropriate part of the exam so it doesn’t feel like an interview right at the beginning of the exam. In the example questions above, you can see I have them grouped into vision and visual function questions for the first part of the exam and health questions for the second half.

Over the course of my practice, I have found these pointed questions to be more helpful in getting the best information out of my patients than asking open-ended questions. But what about you? Are there any you would add or subtract? I’d love to know.

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