Making a Case for the History

There are ever-growing, high-tech diagnostic methods available to us, but the simple case history usually provides 90% of the useful information, with eye examination and diagnostic tests used to confirm the diagnosis. 

The clinical evaluation of any patient, no matter what the discipline, begins with a case history. We are all familiar with the major elements of the case history, from the chief complaint to medications and allergies. The Problem-Oriented Medical Record (POMR) has proven to be a useful method for documenting medical information. It provides a structure that helps us record our patient notes, and view those notes subsequently in a manner that gives us a good understanding of that patient’s history. 

The review of systems (ROS) has become a standard element of the history and the POMR. ROS is a list of questions, arranged by organ system, designed to uncover symptoms of dysfunction and disease.

Applying the ROS 

The ROS can be applied in several ways: 
• As a head-to-toe screening tool asked of every patient. 
• As additional questions asked only of patients who fall into particular risk categories (e.g., reserving questions designed to uncover pseudotumor cerebri to overweight females of child-bearing age.) 
• As a means to describe the likely causes of a presenting symptom (e.g., patients with a chief concern of “unilateral eye and head pain” would merit a detailed headache and neurologic ROS). 

Today’s clinicians incorporate the ROS into the overall patient care strategy. Patients’ responses should be interpreted within the context of the rest of their profile, including demographics, risk factors, past history, and objective data gained from the examination. 

The clinician can then come to an informed conclusion about the extent and cause of the patient’s symptom(s), and use it to guide their subsequent management. There are few functions of the human body that operate singularly, and the visual system is no different. It’s just one part of an overwhelmingly complex structure that continually demands our insight and attention. We owe it to our patients to have a full understanding of how these systems interact so we can provide them with the best treatment and care.  

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