Patient history is a very critical piece to an exam, but is unfortunately often underemphasized and under-appreciated. Our technicians are often responsible for capturing the essence of the chief complaints during the patient work-up, but we all know that is not the end of the road. Asking the correct questions as an optometrist, in order to elicit a more comprehensive response, will improve your knowledge of the patient and their concerns. With the increasing use of telemedicine during the COVID-19 pandemic and beyond, listening critically for key symptoms and phrases will improve outcomes for your patients while increasing your value as an optometrist.
Interpreting patient complaint(s) in order to create a working differential diagnosis list can take years of clinical experience. The list below is a patient complaint to differential diagnosis dictionary to help speed the process and to keep in your back pocket as if you were traveling abroad in a foreign country and didn’t know the language.
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Patient complaint to differential diagnosis
The list below is not exhaustive, but should assist you as you start your clinical career. These responses were obtained from clinical experience, asking optometric colleagues and technicians, as well as a record history diagnosis search and chief complaint review of patients’ responses. Quotation marks are used to quote word-for-word or to emphasize important words that were recorded in a patient's chief complaint.
Demographics (patient age, gender, race) are also very important when creating your differential diagnosis list; consider this when assessing the differential diagnoses listed. And, of course, there is a long list of conditions that often don't have any patient symptoms and thus will not be found in this dictionary. This is why it is imperative to educate your patients on the importance of routine exams, in order to be able to catch these problems before symptoms arise. I challenge you to add to the list and create your own list with your examples as they arise.
| Patient Complaint | Differential Diagnosis |
|---|---|
| “Blue-Tint/Halo to vision” and/or blue flashes | Hollenhorst Plaque/Artery occlusion, entoptic phenomenon |
| Blurry vision, "looks like clouds in my eye" | BRVO wtih macular edema |
| Eyelashes fall out, (2) eyelids glued shut in the morning, (2) “eyelids stick to eye,” eyelids itch | Blepharitis, Demodex, (2) RCE |
| Blurry vision in the morning | Fuchs, Blepharitis, Dry Eye Disease (Lagophthalmos) |
| “Sharp” pain when first opening eyes (not just in the morning), “hurts/grinding feeling” (can awake patient in the middle of the night), “eyelids stick to eye/glued shut,” “feels like sticks in my eye” | RCE |
| Tearing with possible “soreness”, redness, or mild blurry vision | HSV, Herpes Zoster |
| “Zig-zag/Wavy/Flashing lights,” “circle of lights,” “kaleidoscope,” “shimmering” (right or left eye that can spread bilaterally) | Migraine Aura, Retinal Migraine Aura |
| “Dull ache,” “pressure behind eyes” | Sinus Congestion/Infection |
| “I keep cleaning my glasses, but my vision is still blurry,” “film over my vision” | Cataracts, Dry Eye Disease |
| “My arms aren’t long enough,” “takes longer to focus on computer/reading,” “eyelid twitches” | Presbyopia |
| “Spider-web,” “gnats/bugs in my vision” | Vitreous Degeneration (Floaters) |
| Water and itching, stringy discharge | Allergic Conjunctivitis |
| Red and “achey” | Epi-scleritis, scleritis |
| “Feels like I got punched in the eye,” “light sensitivity” | Uveitis |
| “Feels like hair hanging in vision” | Superior visual field defect (BRVO, NAION) |
| “Halo-like imprint” and blur, “fonts look smaller/distorted,” “cloudy vision,” “thought glasses were dirty,” “multiple dots of bright blue light,” “faded” central vision, (2) hole/blind spot in central vision | PED (serous macular detachment), (2) Macular Hole, ERM/VMA, CME |
| Distance and/or Near Blur (better with good light, worse when tired), “eyes feel like they cross,” headaches, eyestrain, “things look blurry when I look away from my computer” | Paresis of Accommodation (ie accommodation insufficiency) |
| “Circle defect,” complete blackness of vision (sup or inf half) | NAION, AION, Papillitis |
| Near Vision Blur + near vision (intermittent) diplopia (worse when reading long periods), sore eyes while reading, words “float” or move on the page | Convergence Insufficiency |
| Foreign body sensation/”feels like something is under my lid,” “contact moves on my eye,” “contacts pop out,” crusty/stringy discharge, “wake up with goop in the corner,” redness | GPC |
| Red and painful, sensitive to light, “watery” | Corneal Ulcer |
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Want this as a cheat sheet?
Download this patient to clinical diagnosis dictionary as a PDF for easy reference!
