OnExam

Identifying Information

Gather the patient's general identifying data.

Chief Complaint (CC)

Elicit the patient’s chief complaint or reason for visit.

History of Presenting Illness (HPI)

Characterize each of the patient's principal symptoms using the OPQRST/OLD CARTS approach.

Decreased Vision

  • Eye pain
  • Red eye
  • Discharge
  • Trauma
  • Floaters
  • Flashes
  • "Curtain" of vision loss
    • Night vision
  • Decreased colour vision
  • Headache
  • Jaw claudication
  • Scalp tenderness
  • Halos
  • Photophobia
  • Neurological symptoms
  • Metamorphosia (visual distortions)
  • Perception of colours
    • Red/pink film over vision
    • Yellowing of colours

Red Eye

  • Eye pain
  • Trauma
  • Foreign body
    • Grinding or hammering
    • Vegetative matter such as branch striking eye
  • Contact lens wearer
    • Contact lens type
    • Changes to contact lens
    • Wearing contacts over night
    • Swimming with contacts
  • Decreased vision
  • Halos
  • Nausea/vomiting
  • Diplopia
  • Photophobia
  • Upper respiratory symptoms
    • Cough
    • Sore throat
  • Rashes
  • Eyelid swelling
  • Other family members or acquaintances with red eye
  • Itchy
  • Discharge
  • Allergies
  • Seasonal pattern
  • HLA B-27 associated symptoms
    • Joint pain
    • Back pain
    • Abdominal pain
    • Hematochezia

Double vision (diplopia)

  • Monocular (double vision remains only in affected eye when unaffected eye is covered)
    • Recent ocular or medical prescription change
    • Trauma
      • Chemicals
      • UV Exposure
      • Burns
    • Yellowing of colours
    • Halos
    • Metamorphosia (visual distortions)
  • Binocular (double vision is eliminated when either eye is covered)
    • Orientation of diplopia
      • Horizontal
      • Vertical
      • Diagonal (i.e. mixed)
    • Neurological symptoms
    • Trauma
      • Chemicals
      • UV Exposure
      • Burns
    • Anisocoria (uneven pupil size)
    • Eye pain
    • Pain on extra-ocular movement
    • Ptosis (eye lip drop)
    • Floaters
    • Flashes
    • Jaw claudication
    • Scalp tenderness
    • Recent eye surgery
    • History of thyroid disease
    • History of eye misalignment
    • History of strabismus surgery

Eye pain

  • Decreased vision
  • Trauma
    • Chemicals
    • UV Exposure
    • Burns
  • Foreign body
    • Grinding or hammering
    • Vegetative matter such as branch striking eye
  • Contact lens wearer
    • Contact lens type
    • Changes to contact lens
    • Wearing contacts over night
    • Swimming with contacts
  • Decreased colour vision
  • Halos
  • Neurological symptoms
  • Nausea/vomiting
  • Diplopia
  • Photophobia
  • Rashes
  • Eyelid swelling
  • Discharge
  • Recent eye surgery
  • Referred pain
    • Dental pain
    • Sinus pain

Photophobia

  • Trauma
    • Chemicals
    • UV Exposure
    • Burns
  • Foreign body
    • Grinding or hammering
    • Vegetative matter such as branch striking eye
  • Recent eye surgery
  • Mydriatic drops
  • Eye pain
  • Red eye
  • Nausea/vomiting
  • Halos
  • Headache

Burning

  • Insulting agents
    • Chemicals
    • Make up
    • Contact lens solution
    • Ocular drops
    • Allergies
    • UV exposure
  • Red eye
  • Discharge
  • Rashes
  • Itchiness
  • Allergies
  • Seasonal pattern

Eye discharge

  • Colour
  • Amount
  • Consistency

Eyelid swelling

  • Trauma
    • Chemicals
    • UV Exposure
    • Burns
  • Insulting agents
    • Chemicals
    • Make up
    • Contact lens solution
    • Ocular drops
    • Allergies
    • UV exposure
  • Erythema
  • Eyelid tenderness
  • Fever
  • Foreign body sensation
  • Pain on extra-ocular movement
  • Recent eye surgery

Ptosis

  • Diplopia
  • Uneven pupil size (anisocoria)
  • Foreign body sensation
  • Neurological symptoms
  • Trauma
    • Chemicals
    • UV Exposure
    • Burns
  • Variability with fatigue
  • History of autoimmune disease (e.g. Lupus, Sjogren syndrome)

Past Ocular History (POHx)

  • Congenital abnormalities
  • Current and past ocular diagnoses
    • Cataracts
    • Glaucoma
    • Age-related macular degeneration
    • Amblyopia
    • Strabismus
  • Past eye trauma/Foreign body removal
  • Past eye surgeries
    • Surgeon
    • Year
    • Complications
  • Past eye procedures
    • Laser
      • Indication (e.g. retinal detachment, glaucoma, diabetic retinopathy, etc.)
    • Lacrimal damage
    • Foreign body removal
    • Eye injections (Intravitreal Injections)
      • Indication (e.g. diabetes, antibiotics, age-related macular degeneration, etc.)
    • Elective procedures
      • LASIK, PRK, etc.
    • Cataract removal
    • Glaucoma (other than laser)
  • Eye prescription (if applicable)
  • Contact lens wear
    • Contact lens type
    • Changes to contact lens
    • Wearing contacts over night
    • Swimming with contacts
  • Optometrist care

Past Medical History (PMHx)

Specifically ask about:

  • Asthma
  • Autoimmune conditions
  • Arrhythmias
  • Bleeding disorders
  • COPD
  • Diabetes
  • Hypertensions
  • Hyperlipidemia
  • HIV
  • Sickle trait
  • Thyroid conditions
  • Coronary artery disease

Family History (FmHx)

  • Autoimmune conditions
  • Blindness
  • Glaucoma
  • Macular degeneration
  • Ocular and/or pituitary tumour
  • Retinal detachment
  • Strabismus
  • Amblyopia
  • Cataracts
  • Hypertension
  • Coronary artery disease
  • Diabetes

Social History (SocHx)

  • Occupation
  • Driving habits
  • Diet

Substance Use History (SubHx)

Specifically ask about:

Ocular Medications (Gtt)

Includes all drops and gels used, make note of:

  • Frequency
  • Which eye
  • Last taken
  • Compliance

Medications (Rx)

Gather complete list, including particularly relevant drugs like:

  • Amioderone
  • Anticoagulants
  • Bisphosphonates
  • Chloroquines
  • Digitalis
  • Diuretics
  • Immunosuppressants
  • Steroids
  • Tamsulosin
  • Topiramate
  • Vitamins for macular degeneration

Allergies

Note allergies and ensure they concord with those listed in the EMR. Make note of the specific reaction and pay particular attention to these relevant allergies:

  • Sulfa
  • Latex
  • Eye drops

Immunizations

Note immunization history as described in the immunization history section.

Review of Systems

Conduct a Review of Systems, keeping other etiologies from your differential in mind.

References

  1. Bickley LS, Szilagyi PG. Bates' Guide to Physical Examination and History-Taking, 11th ed. Baltimore: Lippincott Williams & Wilkins; 2011.
  2. Gerstenblith AT, Rabinowitz MP. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease, 6th ed. Baltimore: Lippincott Williams & Wilkins; 2012.
  3. Harper RA. Basic Ophthalmology, 9th ed. San Francisco: American Academy of Ophthalmology; 2010.