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Name
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Dustin Travers
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DOB
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12/01/1959 (55 years)
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Occupation
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Lorry driver
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History
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I am a 55 year old male lorry driver
who lost vision in the left eye yesterday for a minute. If asked, I did not
close my eyes to check if it was definitely my left eye. There was no pain
and vision in both eyes is now normal. If asked, In the last two months I
admit to losing a little bit of weight unintentionally (2kg), fatigue,
headache and a dull pain in my hip, shoulders, and scalp when combing my
hair. The headache is dull and persistent but I attribute this to stress. I
have taken paracetamol for it which eases it slightly. I have not had
palpitations or any other symptoms including no discharge from the eye or
redness of the eye.
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Past Medical History
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Nil
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Drug History
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Paracetamol
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Family History
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Nil
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Social History
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I do not smoke, drink or take
recreational drugs.
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Introduces self
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0
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1
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Confirms name & age of patient
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0
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1
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Explains reason for consultation
& builds rapport
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0
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1
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Gains consent
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0
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1
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Asks open question
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0
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1
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Establishes site
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0
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1
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Asks about onset
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0
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1
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Elicits character of pain
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0
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1
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Asks if pain radiates (specifically
asks for next stiffness)
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0
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1
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Enquires about exacerbating factors
including coughing, straining, light, sound
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0
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1
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2
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Enquires about alleviating factors
including painkillers
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0
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1
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Asks about duration and changes to
pain over time
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0
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1
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Checks severity of pain
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0
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1
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Checks for associated scalp pain
particularly on combing hair
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0
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1
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Checks for jaw pain when eating and
shoulder/hip muscle ache
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0
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1
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Asks for nausea and vomiting
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0
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1
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Asks for rash and recent illness
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0
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1
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Asks for visual disturbances such as
loss of vision, zigzag lines or flashing lights
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0
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1
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Asks for any warning or aura before
headache
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0
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1
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Asks for any eye watering, discharge
and floaters
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0
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1
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Asks for triggers such as period,
stress, chocolate, cheese or wine
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0
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1
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Checks for loss of sensation,
coordination impairment, weakness, seizures
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0
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1
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Asks about past medical history
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0
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1
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Asks about any family history of
disease
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0
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1
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Establishes any drugs or over the
counter medication patient is on
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0
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1
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Asks if patient has any allergies
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0
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1
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Asks if patient smokes, drinks or
takes recreational drugs
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0
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1
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Elicits patients occupation
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0
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1
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Explores and responds to ideas
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0
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1
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Explores and responds to concerns
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0
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1
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Explores and responds to expectations
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0
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1
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Shows empathy
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0
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1
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Avoids jargon
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0
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1
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Summarises back to patient
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0
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1
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Thanks patient
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0
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1
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Patient global score
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0
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1
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2
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Gives reasonable differential
diagnosis (giant cell arteritis on background of polymyalgia rheumatica,
transient ischaemic attach, tension headache etc.)
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0
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1
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