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Instructions

You are a foundation year doctor in A&E. A patient presents with severe eye pain.

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 Scleritis.
Explain less likely and red flag differential diagnoses could be episcleritis, acute angle closure glaucoma, anterior uveitis.
Suggest investigations of slit lamp examination, phenylephrine blanching test, tonometry.
Suggest laboratory investigations of FBC, ESR, CRP, RF, anti-CCP, ANCA.
Suggest imaging of chest X-ray to rule out associated conditions.
Suggest interventions of urgent ophthalmology referral, high-dose oral NSAIDs, possible oral steroids, rheumatology review for underlying disease control.

Internally Approved

Surname/Nom (1)

Roberts

Given names/Prenoms (2)

Margaret

Date of birth/Date de naissance (4)

07 JUN 1966 (58)

Sex/Sexe (5)

PRESENTING COMPLAINT

You've had severe pain in your left eye for the past three days. The pain is deep and throbbing, keeping you awake at night. Your eye is very red and tender to touch.

IDEAS, CONCERNS AND EXPECTATIONS

You're really worried because you've never had pain this bad in your eye before. You're concerned it might be related to your rheumatoid arthritis.

SYSTEMS REVIEW

Severe deep eye pain, worse with eye movement. Eye is tender to touch. Some light sensitivity. No discharge. Vision slightly blurred. Recently had a flare of joint pain.

PAST MEDICAL HISTORY

Rheumatoid arthritis diagnosed 10 years ago. Currently having a flare of joint symptoms.

DRUG HISTORY

Methotrexate 15mg weekly, Folic acid 5mg weekly, Prednisolone 5mg daily, Paracetamol PRN. No known allergies.

FAMILY HISTORY

Mother had rheumatoid arthritis.

SOCIAL HISTORY

Works as an accountant. Lives with husband. Non-smoker. No alcohol due to methotrexate.