You are a foundation year doctor in GP. A patient presents with red watery eyes.
1. Take a focused history from the patient.
2. Explain your differential diagnoses and management plan to the examiner.
Checklist
History
Introduction
Presenting Complaint
Ideas, concerns and expectations
Summarise & Signpost
Past Ocular History
Past Medical History
Drug History
Family History
Social History
Closing
Management
Internally Approved
Surname/Nom (1)
Wong
Given names/Prenoms (2)
Emily
Date of birth/Date de naissance (4)
14 NOV 1995 (28)
Sex/Sexe (5)
f
PRESENTING COMPLAINT
Your right eye became red and watery three days ago, and now the left is starting to feel the same. You've had a cold for the past week.
IDEAS, CONCERNS AND EXPECTATIONS
You're worried because you work in customer service and don't know how long you should stay off work. You want to know if you need antibiotics.
SYSTEMS REVIEW
Eyes are red and watery. Clear watery discharge. Gritty sensation. Tender lymph nodes in front of ears. Recent cold symptoms with sore throat and runny nose.
PAST MEDICAL HISTORY
None significant.
DRUG HISTORY
Taking over-the-counter paracetamol for cold symptoms. No regular medications. No allergies.
FAMILY HISTORY
No relevant family history.
SOCIAL HISTORY
Works in retail. Lives with housemates. Non-smoker. Occasional alcohol.
