OPTHALMOLOGY History Taking and Examination

Presenting Complaint

The chief complaint sometimes called the “presenting complaint” is the main reason why the patient is in the clinic.

When obtaining information about the onset of a complaint you need to know when the patient started to notice that something was not right and how quickly the symptoms came about. You may have a patient complain about decreased vision. When you ask how long the patient has been noticing the symptoms they may say years. In that case you make think that the patient needs glasses. On the other hand if the patient says that there vision decreased last night and suddenly this could indicate a more serious pathology

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CPT (Third-Party Coding) requires the following 8 pieces of information when collecting a History of the presenting complaint:

  1. Location: Where is the problem?
  2. Duration: How long have you noticed the symptoms.
  3. Context: Is is associated with any other activities.
  4. Modifying factors: What makes it better or worse
  5. Quality: Describe the pain, Is it an ache, an itch, foreign body sensation?
  6. Severity: How would you rate your pain on a scale from 1 to 10?
  7. Associated Signs & Symptoms: Is it associated with a headache?
  8. Timing Do symptoms come and go or are they constant? history from both the guardian/caretaker and the patient.

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