Systematic Ophthalmologic History Taking and Physical Exam (Essay Sample)

TOPIC: SYSTEMATIC OPHTHALMOLOGIC HISTORY TAKING AND EXAMINATION
HISTORY TAKING
In taking the history of patients, it is important to establish a rapport with the patient. General communication skills are needed to accomplish this properly and efficiently. It is important that during the history as well as the physical examination, that it should always be patient-centered. An important rule in obtaining a comprehensive history is to let the patient tell the story, and not to interrupt them during consultation. Use open-ended questions for broad communication with the patient. It is also important to demonstrate empathy in responding to the patient both verbally and non-verbally, it should also be expressed through body language that the physician is actively listening and interested to hear the patient’s story by being relaxed, open and professional and maintaining an appropriate level of eye contact.
1 GENERAL DATA
This is usually the first part of history taking, getting the personal and demographic data. Usually the full name, age, birthdate, address, sex, ethnicity/race, occupation, religion, marital status and also note the date of examination. It is important to know the patient personally to be able to establish a good rapport and for good and efficient patient care as well. Some information such as race and religion are also used in the diagnostic part because some races present with some specific disease conditions not present in other ethnicity and the religion is important during the treatment and management course because some may not allow blood transfusion and others as such.
2 CHIEF COMPLAINT
The chief complaint is usually what prompted the patient to go to the emergency room or to seek consult. It can be a single symptom, but sometimes it can be more than one complaint, the common chief complaints for patients with eye problems are: blurred vision, eye swelling, eye pain, redness, trauma, etc. Have the patient to describe it in their own words if they cannot explain. Always provide enough time for the patient to answer and avoid interrupting and rushing the patient.