A case history is a detailed record of a patient’s medical history, symptoms, and treatment plan. For eye care, it includes:
Key components:
- Chief complaint: Patient’s main issue (e.g., blurred vision)
- History of present illness: Symptoms, duration, severity
- Medical history: Systemic conditions, medications
- Ocular history: Previous eye issues, surgeries
- Family history: Relevant eye conditions
- Social history: Lifestyle, occupation, habits
- Medications: Current medications, allergies
Purpose:
- Accurate diagnosis
- Personalized treatment plan
- Monitoring progress