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Instructions

You are a foundation year doctor in the paediatric eye clinic. A mother has brought in her 3-month-old baby with concerns about her eyes.

1. Take a collateral history from the parent.

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 Congenital Glaucoma.
Explain less likely and red flag differential diagnoses could be megalocornea, trauma, anterior segment dysgenesis.
Suggest bedside investigations of corneal diameter measurement, examination under anesthesia.
Suggest imaging of anterior segment photography.
Suggest interventions of hospital admission for urgent surgical management (goniotomy or trabeculotomy), genetic counseling referral.

Internally Approved

Surname/Nom (1)

Wilson

Given names/Prenoms (2)

Jessica

Date of birth/Date de naissance (4)

31 OCT 2022 (3M)

Sex/Sexe (5)

PRESENTING COMPLAINT

Your baby's eyes seem larger than normal and they water constantly. You've noticed she seems sensitive to light and keeps her eyes closed most of the time. Her right eye appears slightly larger than the left.

IDEAS, CONCERNS AND EXPECTATIONS

You're worried about your baby's development and whether this will affect her vision long-term.

SYSTEMS REVIEW

Eyes water frequently. Photophobic. Otherwise feeding well and gaining weight appropriately. No other concerns.

Instructions

Checklist

Introduction

Presenting Complaint

Ideas, concerns and expectations

Summarise & Signpost

Past Ocular History

Past Medical History

Drug History

Family History

Social History

Closing

PRESENTING COMPLAINT

IDEAS, CONCERNS AND EXPECTATIONS

SYSTEMS REVIEW

PAST MEDICAL HISTORY

DRUG HISTORY

FAMILY HISTORY

SOCIAL HISTORY

Instructions

Checklist

Introduction

Presenting Complaint

Ideas, concerns and expectations

Summarise & Signpost

Past Ocular History

Past Medical History

Drug History

Family History

Social History

Closing

PRESENTING COMPLAINT

IDEAS, CONCERNS AND EXPECTATIONS

SYSTEMS REVIEW

PAST MEDICAL HISTORY

DRUG HISTORY

FAMILY HISTORY

SOCIAL HISTORY

Feedback History

No Sessions Recorded

Score Analysis