Print
PDF
Name
|
Alison Ash
|
DOB
|
01/06/1992
(24 years)
|
Occupation
|
Hairdresser
|
History
|
I am
scared I might be going blind. I have had diabetes since I was a child and I
know that losing your sight is a complication if it is poorly controlled
(which it isn’t!) and yesterday, I had a sudden loss of vision in my left
eye. It is painful if I try to move it and nothing has seemed to make the
vision come back. This has happened once before a few months ago and at that
time, it was a sudden blurring of my vision, with special difficulty in
seeing red things. Besides this, I have been feeling quite tired for the last
six months, probably because we are low on staff at work. Sometimes my body
feels weaker and I’m getting clumsier at work. I also have some tingling in
my legs which I’m worried is due to my diabetes, and this is worse after I
take a hot bath.
|
Past Medical History
|
Type 1 DM
since 12 years
|
Drug History
|
Insulin
injections, NKDA
|
Family History
|
Mum and
maternal aunt have Type 1 DM.
|
Social History
|
Smokes
5-10/day (6 years), drinks occasionally at weekends (a couple of glasses of
wine), no recreational drug use.
Lives with
long-term partner of 4 years.
|
Introduction
and consent
|
|
Name, age,
occupation
|
|
Presenting
complaint
|
|
History of
Presenting Complaint (onset, duration, fields affected)
|
|
Associated
features (red eye, discharge, pain)
|
|
Previous
episodes
|
|
Any
associated features (sensory changes – pins and needles/numbness, weakness/falls,
bowel/bladder changes, confusion, speech changes)
|
|
Red flags:
headache (worse on coughing/bending/with vomiting), loss of consciousness, recent trauma
|
|
Constitutional
symptoms (fever, weight loss, malaise, loss of appetite)
|
|
Past
Medical History
|
|
Family
History
|
|
Drug
History and allergies
|
|
Social
History (smoking, alcohol, drugs)
|
|
Ideas e.g.
“Was there anything you thought it might be?”
|
|
Concerns
e.g. “What about it is worrying you in particular?”
|
|
Expectations
e.g. “Is there anything particular, you’re hoping we could do for you?”
|
|
Summarizes
and thanks patient
|
|
Offer
differentials (optic neuritis, multiple sclerosis, screen for amaurosis
fugax, retinal detachment) and appropriate follow up (fundoscopy, bloods, imaging
– MRI scans)
|