You are a foundation year doctor in GP. A patient presents with a red eye.
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)
Mitchell
Given names/Prenoms (2)
Sarah
Date of birth/Date de naissance (4)
14 JUL 1991 (32)
Sex/Sexe (5)
f
PRESENTING COMPLAINT
Your right eye became red and slightly uncomfortable two days ago. You've had similar episodes before that went away on their own.
IDEAS, CONCERNS AND EXPECTATIONS
You're worried because this is the third episode this year. You want to know if it's serious and if there's anything you can do to prevent it happening again.
SYSTEMS REVIEW
Mild discomfort but no severe pain. Slight watering of the eye. Mild light sensitivity. No change in vision. No discharge. The redness is mainly in one area of the eye.
PAST MEDICAL HISTORY
Two previous episodes of red eye this year, each lasting about 10 days. Otherwise healthy.
DRUG HISTORY
No regular medications. No known allergies.
FAMILY HISTORY
No relevant family history.
SOCIAL HISTORY
Works as a teacher. Lives with partner. Non-smoker. Occasional alcohol.
