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Preparing your case...

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Instructions

You are a foundation year doctor in GP. A patient presents with itchy eyes.

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 Seasonal Allergic Conjunctivitis.
Explain less likely and red flag differential diagnoses could be viral conjunctivitis, vernal keratoconjunctivitis.
Suggest investigations of visual acuity.
Suggest interventions of topical antihistamine/mast cell stabilizer drops, artificial tears, allergen avoidance advice, optimization of oral antihistamines.

Internally Approved

Surname/Nom (1)

Parker

Given names/Prenoms (2)

Thomas

Date of birth/Date de naissance (4)

27 SEPT 2001 (22)

Sex/Sexe (5)

PRESENTING COMPLAINT

Your eyes have become very itchy and watery over the past week. This happens every summer when your hay fever starts.

IDEAS, CONCERNS AND EXPECTATIONS

You've tried over-the-counter antihistamine tablets but they're not helping enough. You want something more effective for your eyes specifically.

SYSTEMS REVIEW

Both eyes itchy and watery. Clear discharge. Also experiencing sneezing, runny nose, and itchy throat. Symptoms worse when outdoors. No pain. No change in vision.

PAST MEDICAL HISTORY

Hay fever every summer since teenage years.

DRUG HISTORY

Cetirizine 10mg daily during summer months. No regular medications. No allergies.

FAMILY HISTORY

Father has hay fever.

SOCIAL HISTORY

University student. Lives in shared accommodation. Non-smoker. Occasional alcohol.