Is it true? Can an eye-care provider read the patient chief complaint, before seeing the patient, and know the diagnosis? Many times, the answer is, yes.

Some very common complaints can lead to the diagnosis before the physical exam is performed. This article will describe: 1) how to elicit a description from the patient that includes the chief complaint and history of present illness, 2) common chief complaints, and 3) conditions based on patient descriptions with the most common diagnosis derived from those descriptions.

Eliciting a description

So, how do we elicit a “description” from the patient? First, we want to identify the patient’s chief complaint (CC). The CC is written in the chart in the patients’ own words. It is what is troubling them about their eye(s) or vision that has brought them in to see the doctor. The National Institutes of Health define the CC as “a concise statement in English or other natural language of the symptoms that caused a patient to seek medical care.”

When writing down the chief complaint, we document it in the patient’s record exactly how they say it. Usually this is written in one or two sentences. The CC sets the foundation of the whole examination going forward.

We follow the CC by eliciting the history of present illness (HPI), which elaborates on and supports the CC. We can collect the HPI by covering the following elements and asking the patient these specific questions:

1. Location. Which eye or both?
2. Severity. How bad is the problem?
3. Quality. The adjective that describes the condition ( “red” eye, “blurred” vision, “sticky” discharge
4. Timing. When during the day do you notice the symptoms?
5. Context. Does any activity make it worse or better ? Or, what are you doing when you notice the problem?
6. Duration. How long have you had the problem?
7. Modifying factors. What have you tried that makes it better, worse or had no effect? Have they seen another doctor?
8. Associated signs and symptoms. Are you experiencing other signs or symptoms (whether the patient thinks it’s important or not).

With the CC and HPI definitions behind us, Table 1 reviews some common complaints (symptoms) and possible diagnoses. Table 2 provides examples of CCs with HPI questions that will help determine the diagnosis.

Conclusion

We have defined the CC and HPI and reviewed common patient complaints with their possible diagnoses. After the patient reveals the complaint, the questions we as technicians ask should be straightforward. The various answers provided by the patient lead the eye-care provider toward a definitive diagnosis. OP

Sergina M. Flaherty, COMT, OSC, CTC, (F)ATPO, is senior ophthalmic technician at Stone Oak Ophthalmology in San Antonio, Texas.