You are a foundation year doctor in the eye clinic. A patient presents with recurrent episodes of blurred vision.
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)
Zhang
Given names/Prenoms (2)
Michael
Date of birth/Date de naissance (4)
05 MAR 2001 (23)
Sex/Sexe (5)
m
PRESENTING COMPLAINT
You've had several episodes of blurred vision in your right eye over the past year. Each episode lasts a few days and then completely resolves. Your eye isn't particularly red or painful during these episodes. This is your third episode this year.
IDEAS, CONCERNS AND EXPECTATIONS
You're worried about these recurring episodes and whether they might cause permanent damage to your vision. You want to know what's causing them and if they can be prevented.
SYSTEMS REVIEW
No eye pain or significant redness. No headaches. No other visual symptoms between episodes. Otherwise well.
PAST MEDICAL HISTORY
H. pylori infection treated last year. Otherwise healthy.
DRUG HISTORY
None. No allergies.
FAMILY HISTORY
No family history of eye problems.
SOCIAL HISTORY
University student. Lives in shared accommodation. Non-smoker. Occasional alcohol.
