You are a foundation year doctor in the eye clinic. A patient presents with gradual vision loss.
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)
Edwards
Given names/Prenoms (2)
Patricia
Date of birth/Date de naissance (4)
19 SEPT 1948 (75)
Sex/Sexe (5)
f
PRESENTING COMPLAINT
Your vision has been getting gradually worse over the past year. Colors seem less bright and everything looks slightly yellow. Surprisingly, you've found you need your reading glasses less than before.
IDEAS, CONCERNS AND EXPECTATIONS
You're worried about going blind. Your sister had something similar and had surgery for it. You want to know if you need surgery too.
SYSTEMS REVIEW
No eye pain or redness. No flashing lights or floaters. No double vision. Vision worse in bright light and when driving at night. Wear glasses for distance but finding you need reading glasses less often lately.
PAST MEDICAL HISTORY
Hypertension for 10 years. Type 2 diabetes diagnosed 5 years ago. No previous eye surgery.
DRUG HISTORY
Metformin 500mg twice daily, Ramipril 5mg once daily, Aspirin 75mg once daily. No known drug allergies.
FAMILY HISTORY
Sister had cataract surgery last year. Mother had glaucoma.
SOCIAL HISTORY
Retired librarian. Lives with husband. Still drives but finding it difficult, especially at night. Non-smoker. Occasional alcohol.
