Print
PDF
Name
|
Theodore Alfredson
|
DOB
|
18/09/1982 (32 years)
|
Occupation
|
Accountant
|
History
|
I am an untalkative 32 year old male
accountant with left eye pain and pain at the temple. If asked directly,
admits that the pain is around the eye rather than in the eye. The pain lasts
an hour with watering of the eye and has occurred at least 10 times in the
last week. Each time the eye gets really red and waters up. There is no
warning before it starts or trigger. It can happen anywhere. There’s no
vision loss, discharge from the eye, history of trauma/surgery, fever, neck
stiffness or any other symptom.
|
Past Medical History
|
Nil
|
Drug History
|
Nil
|
Family History
|
I smoke 10 cigarettes a day for 10
years and drink very occasionally. I don't use recreational drugs. I don’t
have any allergies.
|
Social History
|
I'm worried that this is being caused
by stress at work. There are so many deadlines but I am coping.
|
Introduces self
|
0
|
1
|
|
Confirms name & age of patient
|
0
|
1
|
|
Explains reason for consultation
& builds rapport
|
0
|
1
|
|
Gains consent
|
0
|
1
|
|
Asks open question
|
0
|
1
|
|
Establishes site
|
0
|
1
|
|
Asks about onset
|
0
|
1
|
|
Elicits character of pain
|
0
|
1
|
|
Asks if pain radiates (specifically
asks for next stiffness)
|
0
|
1
|
|
Enquires about exacerbating factors
including coughing, straining, light, sound
|
0
|
1
|
2
|
Enquires about alleviating factors
including painkillers
|
0
|
1
|
|
Asks about duration and changes to
pain over time
|
0
|
1
|
|
Checks severity of pain
|
0
|
1
|
|
Asks for nausea and vomiting
|
0
|
1
|
|
Asks for rash and recent illness
|
0
|
1
|
|
Asks for visual disturbances such as
loss of vision, zigzag lines or flashing lights
|
0
|
1
|
|
Asks for any warning or aura before
headache
|
0
|
1
|
|
Asks for any eye watering, discharge
and floaters
|
0
|
1
|
|
Asks for triggers such as period,
stress, chocolate, cheese or wine
|
0
|
1
|
|
Checks for loss of sensation,
coordination impairment, weakness, seizures
|
0
|
1
|
|
Asks about past medical history
|
0
|
1
|
|
Asks about any family history of
disease
|
0
|
1
|
|
Establishes any drugs or over the
counter medication patient is on
|
0
|
1
|
|
Asks if patient has any allergies
|
0
|
1
|
|
Asks if patient smokes, drinks or
takes recreational drugs
|
0
|
1
|
|
Elicits patients occupation
|
0
|
1
|
|
Explores and responds to ideas
|
0
|
1
|
|
Explores and responds to concerns
|
0
|
1
|
|
Explores and responds to expectations
|
0
|
1
|
|
Shows empathy
|
0
|
1
|
|
Avoids jargon
|
0
|
1
|
|
Summarises back to patient
|
0
|
1
|
|
Thanks patient
|
0
|
1
|
|
Patient global score
|
0
|
1
|
2
|
Gives reasonable differential
diagnosis (cluster headache, migraine, tension type etc.)
|
0
|
1
|