mlawizard

Preparing your case...

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Instructions

You are a foundation year doctor in GP. A patient presents with red eyes.

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 Bacterial Conjunctivitis.
Explain less likely and red flag differential diagnoses could be viral conjunctivitis, allergic conjunctivitis, early keratitis.
Suggest investigations of visual acuity, fluorescein staining if corneal involvement suspected.
Suggest interventions of chloramphenicol drops/ointment, advice on hand hygiene, removal of contact lenses if worn, return if symptoms worsen/don't improve in a week.

Internally Approved

Surname/Nom (1)

O'Brien

Given names/Prenoms (2)

James

Date of birth/Date de naissance (4)

15 JUL 1989 (34)

Sex/Sexe (5)

PRESENTING COMPLAINT

Both your eyes have been red and sticky for the past two days. It started in your right eye and spread to the left. Your eyes are particularly stuck together when you wake up in the morning.

IDEAS, CONCERNS AND EXPECTATIONS

You're worried about it spreading to your young children. You want to know how long you need to be off work - you work in a school.

SYSTEMS REVIEW

Eyes feel gritty and uncomfortable. Green-yellow discharge that's worse in the morning. No significant pain. No change in vision. No light sensitivity.

PAST MEDICAL HISTORY

None significant. No previous eye problems.

DRUG HISTORY

No regular medications. No known allergies.

FAMILY HISTORY

No relevant family history.

SOCIAL HISTORY

Primary school teacher. Lives with partner and two young children. Non-smoker. Occasional alcohol.