By Aayushi Pandya (4th year Medical Student)
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)