You are a foundation year doctor in A&E. A patient presents with acute eye pain and headache.
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)
Chen
Given names/Prenoms (2)
Linda
Date of birth/Date de naissance (4)
18 AUG 1968 (55)
Sex/Sexe (5)
f
PRESENTING COMPLAINT
You woke up 2 hours ago with severe pain in your right eye and a bad headache. Your vision is blurred and you feel sick. The pain is worse than anything you've experienced before. You've also noticed colored halos around lights.
IDEAS, CONCERNS AND EXPECTATIONS
You're terrified as you've never had eye problems before. The pain is unbearable and you're worried you might lose your vision.
SYSTEMS REVIEW
Right eye is red and painful. Vision is very blurry. Seeing rainbow-colored rings around lights. Feeling nauseous with a frontal headache. No discharge or injury.
PAST MEDICAL HISTORY
Long-sighted, wears reading glasses. No previous eye problems.
DRUG HISTORY
None. No known allergies.
FAMILY HISTORY
No known family history of eye problems.
SOCIAL HISTORY
Works as a teacher. Lives with husband. No smoking. Occasional alcohol.
