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Preparing your case...

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Instructions

You are a foundation year doctor in the eye clinic. A patient presents with gradual vision loss.

1. Take a focused history from the patient.

2. Explain your differential diagnoses and management plan to the examiner.

Checklist

History

Introduction

Adheres to appropriate infection control.
Introduces themselves by name and role.
Confirms identity of patient.
Explains procedure in simple terms.
Gains consent.

Presenting Complaint

"What's brought you in today?"
Asks which eyes are affected
Asks about onset and progression of symptoms.
Explores visual disturbance.
Explores eye pain using SOCRATES approach.
Asks about red eye.
Asks about eye discharge, watery eyes.
Asks about dry eyes, grittiness.
Asks about itchy eyes.
Asks about photophobia.
If relevant, asks about eye trauma.
Asks about impact of symptoms on daily activities.

Ideas, concerns and expectations

"Is there anything you think could be causing this?"
"Do you have any concerns about your symptoms?"
"What are you hoping I can do for you today?"

Summarise & Signpost

Summarises the presenting complaint.
Asks if anything has been missed.
"I’d like to move on to finding out a bit more about your health and your day-to-day life."

Past Ocular History

Asks about previous similar episodes.
Asks about previous eye problems or diagnoses.
Asks about previous eye trauma or surgery.
Asks about use of prescription glasses or contact lenses.

Past Medical History

Asks about currently undergoing investigations.
Asks about medical diagnoses and previous surgeries.
Asks about allergies and reactions.

Drug History

Asks about prescribed medications, including eyedrops.
Asks about over-the-counter medications.
Asks about supplements and home-remedies.

Family History

Asks about family history of eye conditions such as glaucoma, macular degeneration.
Asks about family history of systemic conditions such as diabetes, hypertension.

Social History

Asks about home life and support network.
Asks about smoking, alcohol, and recreational drug use.
Asks about occupation, especially if it involves eye strain or risk of eye injury.
Asks about driving.
Asks about diet and exercise.

Closing

Summarises key points.
"Do you have any questions?"
Thanks patient.
Adheres to appropriate infection control.

Management

Explain most likely differential diagnosis is Primary Open Angle Glaucoma.
Explain less likely and red flag differential diagnoses could be normal tension glaucoma, secondary glaucoma, retinal detachment.
Suggest investigations of visual acuity, visual fields, tonometry, gonioscopy, fundoscopy.
Suggest laboratory investigations of blood glucose, HbA1c.
Suggest imaging of optic disc photography, OCT.
Suggest interventions of topical prostaglandin or beta-blocker drops, referral to glaucoma specialist.

Bonus Questions

Explain most likely differential diagnosis is Primary Open Angle Glaucoma.
Explain less likely and red flag differential diagnoses could be normal tension glaucoma, secondary glaucoma, retinal detachment.

Internally Approved

Surname/Nom (1)

Thompson

Given names/Prenoms (2)

George

Date of birth/Date de naissance (4)

11 JUN 1955 (68)

Sex/Sexe (5)

PRESENTING COMPLAINT

You have noticed your vision gradually getting worse over the past year. You feel like you're looking through a tunnel and sometimes miss things in your peripheral vision. You recently knocked over a cup of tea because you didn't see it on the edge of the table. You have no pain in your eyes.

IDEAS, CONCERNS AND EXPECTATIONS

You're worried about going blind as your sister has glaucoma. You want to know if this is related and if it can be treated.

SYSTEMS REVIEW

You have no eye pain, redness, or discharge. No flashing lights or floaters. No double vision. You wear glasses for reading. You have mild hypertension and type 2 diabetes.

PAST MEDICAL HISTORY

Hypertension diagnosed 5 years ago. Type 2 diabetes diagnosed 3 years ago. No previous eye problems or surgery.

DRUG HISTORY

Metformin 500mg twice daily, Ramipril 5mg once daily. No known drug allergies.

FAMILY HISTORY

Sister has glaucoma. Father had diabetes.

SOCIAL HISTORY

Retired accountant. Lives with wife. Independent with activities of daily living. Ex-smoker (quit 10 years ago). Occasional alcohol.