1. CASE HISTORY
|
Case history is the most important procedure in the entire repertoire of examination procedures and it is one of the most difficult to learn. History-taking can be mastered only after the acquisition of a broad base of knowledge and after years of clinical experience. An experienced and knowledgeable clinician often can determine the diagnosis from the history alone. Conversely, the novice is frequently overwhelmed by the information gathered in the case history and is rarely able to effectively use the information in his diagnostic process. It is beyond the scope of this book to provide sufficient information for a novice clinician to conduct a proficient, comprehensive case history. Rather, a script is presented illustrating the main components of a case history for a typical primary care examination.
The case history is usually conducted at the beginning of the examination, and is the time for the clinician and the patient to become acquainted. The clinician must present himself to the patient as a caring and empathetic individual if he expects the patient to comply with his advice. At the same time, the clinician begins the diagnostic thought process by asking the patient appropriate questions to determine the potential causes for the patient's symptoms. The information is then used in deciding which procedures the clinician will use to confirm or rule out each potential diagnosis. During the case history the clinician also has an opportunity to begin educating the patient about his visual function and about his ocular and general health.
The case history is divided into three main parts: the Interview, the Questionnaire, and the Summary. In the interview portion, the clinician asks open-ended questions in order to assess the patient's reason for seeking care (the chief complaint) and to ascertain the visual needs of the patient's daily life (visual demands). If the patient does not initially volunteer a complaint, it is wise to ask key. Probing questions about his vision and visual function (visual efficiency).
The second portion of the case history, the questionnaire, consists of a series of questions to determine if the patient is at risk for any of a variety of ocular or neurological disorders. During the questionnaire the clinician asks about the patient's previous ocular history, his medical history, and his family's ocular and medical history. The clinician also gives the patient a list of symptoms of common eye problems to find out if the patient has ever experienced any of them. Some clinicians gather this information in a written questionnaire that the patient fills out prior to the examination. While this is an efficient method of data collection, many clinicians prefer to speak directly with the patient about these concerns.
Finally, the case history concludes with a brief recapitulation, or summary, of the patient's chief complaint or complaints, but this time in the clinician's words. This summary assures both the clinician and the patient that the clinician understands the patient's concerns, and gives the patient an opportunity to add anything that may have been missed. |
