mlawizard

Preparing your case...

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Instructions

You are a foundation year doctor in GP. A patient presents with chronic eye symptoms.

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 Perennial Allergic Conjunctivitis.
Explain less likely and red flag differential diagnoses could be atopic keratoconjunctivitis, chronic blepharitis.
Suggest investigations of visual acuity.
Suggest interventions of topical antihistamine/mast cell stabilizer drops, artificial tears, environmental modifications (dust mite covers, air filters), allergy specialist referral consideration.

Internally Approved

Surname/Nom (1)

Ahmed

Given names/Prenoms (2)

Rachel

Date of birth/Date de naissance (4)

09 JUN 1978 (45)

Sex/Sexe (5)

PRESENTING COMPLAINT

Your eyes are constantly itchy and irritated. The symptoms are worse when you're at home, especially in the bedroom. This has been going on for several months.

IDEAS, CONCERNS AND EXPECTATIONS

You're frustrated because the symptoms never completely go away. You want to know if there's something in your environment triggering this.

SYSTEMS REVIEW

Bilateral eye itching and irritation. Clear watery discharge. Also get sneezing and stuffy nose at home. Symptoms improve when away from home. No pain. No vision changes.

PAST MEDICAL HISTORY

Asthma since childhood, well-controlled. Diagnosed with dust mite allergy 5 years ago.

DRUG HISTORY

Salbutamol inhaler PRN, Clenil inhaler BD. Tried various over-the-counter antihistamines. No known allergies.

FAMILY HISTORY

Mother has asthma.

SOCIAL HISTORY

Works from home as a graphic designer. Lives with family and pet cat. Non-smoker. No alcohol.