You are a foundation year doctor in the eye clinic. A patient presents with deteriorating 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)
Clarke
Given names/Prenoms (2)
Simon
Date of birth/Date de naissance (4)
06 MAY 1982 (42)
Sex/Sexe (5)
m
PRESENTING COMPLAINT
Your vision has been getting worse over the past 6 months, especially when reading or looking at your computer screen. It's particularly bad in bright light. You're finding it harder to read small print even with your usual reading glasses.
IDEAS, CONCERNS AND EXPECTATIONS
You're concerned because you're quite young to be having eye problems. You're worried about your job as you need good vision for computer work. You want to know if this is related to your medication.
SYSTEMS REVIEW
No eye pain or redness. No flashing lights or floaters. Vision worse in bright light and when trying to read. No other visual symptoms.
PAST MEDICAL HISTORY
Severe asthma requiring frequent steroid courses. Osteoporosis diagnosed last year.
DRUG HISTORY
Seretide inhaler, Prednisolone 10mg daily long-term, Salbutamol inhaler PRN, Alendronic acid weekly. No known drug allergies.
FAMILY HISTORY
No family history of eye problems.
SOCIAL HISTORY
Works as a software developer. Lives with partner. Non-smoker. No alcohol.
