2.1 Patient history, chief complaint & ocular/medical history
Key Takeaways
- The chief complaint is recorded in the patient's own words; the HPI expands it using OLD CART or LOCATES to capture onset, character, timing, and severity.
- Systemic diseases directly affect the eye: diabetes causes retinopathy, hypertension causes vascular occlusions, and Graves' thyroid disease causes proptosis and lid retraction.
- High-yield ocular-toxic drugs include hydroxychloroquine (bull's-eye maculopathy), tamsulosin (IFIS), amiodarone (vortex keratopathy), and corticosteroids (cataract and raised IOP).
- Family ocular history matters most for glaucoma, macular degeneration, and retinal detachment, which cluster in families.
- A complete ophthalmic history has eight components: CC, HPI, past ocular history, past medical history, medications, allergies, family history, and social history.
The Ophthalmic History
The patient history is the foundation of every clinical encounter. As a Certified Ophthalmic Technician (COT) you often perform the initial workup, so a complete, organized history directs the physician's examination, protects the patient, and supports accurate coding. The IJCAHPO COT examination expects you to know each standard component of the ophthalmic history and to recognize how systemic disease and systemic medications affect the eye.
Components of a Complete Ophthalmic History
A complete history includes eight standard components:
- Chief complaint (CC) — the reason for the visit in the patient's words
- History of present illness (HPI) — the detailed story of the current problem
- Past ocular history (POH) — prior eye disease, surgery, and correction
- Past medical history (PMH) — systemic conditions affecting the eye
- Medications — systemic and ocular drugs, with dose and duration
- Allergies — drugs, latex, and preservatives, with the reaction
- Family history — inherited eye disease such as glaucoma and macular degeneration
- Social history — tobacco, alcohol, occupation, and visual demands
Chief Complaint and History of Present Illness
The chief complaint (CC) is the patient's stated reason for the visit, recorded in the patient's own words and kept brief — for example, "blurry vision in the right eye for three days." The history of present illness (HPI) expands the CC into a chronological, detailed narrative. Two mnemonics keep that narrative complete. OLD CART prompts Onset, Location, Duration, Character, Aggravating factors, Relieving factors, and Timing. LOCATES prompts Location, Other associated symptoms, Character, Aggravating and alleviating factors, Timing, Environment, and Severity. Whichever tool you use, always document laterality (OD, OS, or OU), severity on a 0-10 scale, and whether the symptom is constant or intermittent.
| Letter | OLD CART | LOCATES |
|---|---|---|
| 1 | O — Onset | L — Location |
| 2 | L — Location | O — Other symptoms |
| 3 | D — Duration | C — Character |
| 4 | C — Character | A — Aggravating/alleviating |
| 5 | A — Aggravating factors | T — Timing |
| 6 | R — Relieving factors | E — Environment |
| 7 | T — Timing | S — Severity |
Conducting the Interview
Begin by confirming the patient's identity with two identifiers, then use open-ended questions ("What brings you in today?") before narrowing to closed, specific questions. Listen for red-flag symptoms that require prompt physician attention: sudden vision loss, flashes and floaters (possible retinal detachment), a curtain or shadow in the field, halos around lights with pain and nausea (possible acute angle-closure glaucoma), double vision, and eye trauma or chemical exposure. Record findings objectively and avoid leading the patient. When there is a language barrier or the patient is a minor or cognitively impaired, document who provided the history.
The 'A' and 'R' in the OLD CART mnemonic prompt the technician to record which two features of a symptom?
Past Ocular History
The past ocular history (POH) records prior eye conditions, surgeries, and corrective wear. Ask about glasses or contact lenses, refractive surgery (LASIK, PRK), cataract or retinal surgery, prior injury, amblyopia ("lazy eye"), strabismus, glaucoma, and any history of eye infections such as herpetic keratitis. Note current spectacle or contact-lens use and the age of the most recent prescription, because that context explains many chief complaints.
Past Medical History
Systemic disease is inseparable from eye care, so the past medical history (PMH) must be thorough. Diabetes mellitus is the leading cause of new blindness in working-age adults and drives diabetic retinopathy and fluctuating refraction; always record the type, control (HbA1c if known), and years since diagnosis. Hypertension produces hypertensive retinopathy and predisposes to retinal vein and artery occlusions. Thyroid disease — especially Graves' disease — causes proptosis, lid retraction, and restrictive extraocular muscle changes (thyroid eye disease). Also document autoimmune conditions such as rheumatoid arthritis (dry eye, scleritis), sarcoidosis and multiple sclerosis (uveitis, optic neuritis).
Review of Systems
A brief review of systems (ROS) screens body systems relevant to eye disease — for example, joint pain and rashes (autoimmune uveitis), headaches and jaw claudication in older adults (giant cell arteritis, an emergency), and neurologic symptoms such as weakness or numbness (multiple sclerosis). The ROS complements the PMH and often uncovers undiagnosed systemic disease.
A patient reports a history of Graves' disease. Which ocular finding is most directly associated with this thyroid condition?
Medications with Ocular Effects
Every systemic medication belongs in the record because many affect the eye. High-yield examples for the COT exam appear below.
| Systemic drug (class) | Ocular effect |
|---|---|
| Hydroxychloroquine / chloroquine (Plaquenil) | Bull's-eye maculopathy / retinal toxicity |
| Tamsulosin (Flomax) and other alpha-blockers | Intraoperative floppy iris syndrome (IFIS) |
| Amiodarone | Corneal verticillata (vortex keratopathy), optic neuropathy |
| Corticosteroids (systemic or topical) | Cataract, elevated IOP / steroid-response glaucoma |
| Topiramate (Topamax) | Acute angle-closure glaucoma, transient myopia |
| Ethambutol | Optic neuropathy with reduced color vision |
| Tamoxifen | Crystalline retinopathy |
Ask specifically about over-the-counter drops, herbal products, and the dose and duration of any drug, because retinal toxicity from hydroxychloroquine is dose- and time-dependent.
Allergies, Family, and Social History
Record allergies to medications, latex, and preservatives, noting the specific reaction (rash versus anaphylaxis) so the physician can choose safe drops and dyes. Family ocular history is essential: primary open-angle glaucoma, age-related macular degeneration, and retinal detachment cluster in families, and a first-degree relative with glaucoma raises risk severalfold. Finally, social history — tobacco (a major risk factor for macular degeneration and thyroid eye disease), alcohol, occupation, driving needs, and hobbies — shapes both diagnosis and the patient's functional visual goals. Together these components create a medical-legal document and a clinical roadmap for the physician.
Long-term hydroxychloroquine (Plaquenil) therapy requires periodic retinal screening because it can cause which ocular complication?