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History Taking

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TehminaAli
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13 views20 pages

History Taking

Uploaded by

TehminaAli
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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Clinical Skills -

History Taking
Importance and significance of history
taking
Learning objectives
• Introduction to History Taking
• Importance of history taking in clinical practice.
• Components of history taking
• Communications skills in history taking
• Challenges in history taking
Introduction to History Taking
• History taking is the process of gathering information
about a patient’s condition to form the foundation for
diagnosis, management, and treatment.
• In optometry, it provides key insights into the patient's
visual, medical, and lifestyle factors that can affect eye
health and vision.
Importance of History Taking
• First Step to Diagnosis: Helps identify the cause of
symptoms.
• Guides Clinical Testing: Prioritizes which diagnostic tests
to perform.
• Builds Trust: Establishes rapport with the patient through
effective communication.
• Holistic View of Health: Considers both ocular and
systemic factors.
• Legal Record: Serves as documentation for patient care
and legal purposes.
Components of History Taking
• Identification of patient
• Chief Complaints
• Present illness
• Ocular History
• Medical history
• Family history
• Social history
1. Identification of patient
• Name
• Age
• Gender
• Ethnicity
• Contact number
2. Chief Complaints
• The primary reason the patient visits the clinic.
• Use open-ended questions to explore:
"What brings you in today?“
"How long have you noticed this issue?“
• This section captures the patient’s perspective on their
problem.
3. Present Illness
• A detailed exploration of the current problem.
• It uses tools like : SOCRATES:
• Site, Onset, Character, Radiation, Associated symptoms,
Time course, Exacerbating factors, Severity.
• OPQRST: Onset, Provoking factors, Quality, Radiation,
Severity, Timing.
3. Present Illness
• Example : A patient with headaches: "When did the
headache start? "Does it get worse at a specific time of
day?"
4. Ocular History
• Past eye conditions (e.g., infections, surgeries, trauma).
• Use of glasses, contact lenses, or low vision aids.
• Any complaints about : Blurred vision, floaters, redness,
itching .
• Recent changes in vision: Loss of sharpness, difficulty
reading, or seeing at night.
5. Medical History
• Chronic diseases like diabetes, hypertension, or thyroid
issues that affect vision .
• Current medications that can have ocular side effects
(e.g., steroids, antihistamines).
• Allergies that could affect the eyes or influence treatment
plans.
6.Family History
• Conditions like glaucoma, cataract, or retinal
degeneration .
• Helps predict the hereditary risk for diseases.
7. Social History
• he patient’s occupation and its visual demands .
• Example: Prolonged screen use in IT professionals may
cause digital eye strain.
• Lifestyle factors : Smoking (increases risk of cataract and
macular degeneration).
• Alcohol use and recreational drug history .
• Hobbies: Reading, gaming, or sports that impact vision
care strategies.
Communications skills in History
Taking
• Use of open vs. closed-ended questions .
• Active listening: Eye contact, paraphrasing, and empathy.
• Avoiding medical jargon with patients .
• Handling difficult patients (e.g., pediatric or non-
cooperative adults).
Recording and Documentation of
History
• Importance of accurate record-keeping .
• Use of SOAP notes:
Subjective: What the patient reports.
Objective: Clinician's observations.
Assessment: Diagnostic impressions .
Plan: Management strategies.
Challenges in History Taking
• Uncooperative patients (e.g., children or elderly
individuals with cognitive issues).
• Language barriers that affect communication .
• Patients may omit important information, requiring follow-
up questions.
Scenarios
• Patient with headache and blurred vision
• A 45-year-old patient complains of frequent headaches

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