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INSTRUCTIONS FOR THE DOCTOR

This is a short case.

Please take a focused history. Request the findings of an appropriate physical examination. Explain your management to Roger.

Scenario

Roger Chin is a 57-year-old financial planner who is a regular patient of the practice. He is generally healthy and is on perindopril (Coversyl) for hypertension. He is happily married with three grown children and two grandchildren. Along with most of his family he does get classic migraines but rarely in recent years. He called early this morning and asked to be seen urgently.

The following information is on his summary sheet:

  • Age

  • 57

  • Past medical history

  • Hypertension

  • Migraine with aura

  • Medication

  • Perindopril 5 mg mane

  • Eletriptan (Relpax) 40 mg stat prn

  • Allergies

  • Nil known

  • Immunisations

  • Up-to-date

  • Social history

  • Married to Dorothy

  • Non-smoker

  • Occasional alcohol

  • Family history

  • Hypertension

  • Migraine.

INSTRUCTIONS FOR THE PATIENT, ROGER CHIN

Last night you noticed intermittent bright flashes in the temporal field of your left eye, ‘a bit like lightning bolts’. It was provoked by moving your eye and was worse when you turned the light out. You were looking out the window and thought it was lightning but then noticed it inside the house as well.

The bright flashes have gone, but you now have a blurry floating opacity in the middle of your left eye’s vision. It wafts around with the movement of your eye. You called the surgery for an urgent appointment as you were worried.

In answer to specific questioning:

There is no pain; no headache; you have not had this before. The only trouble you have had with your eyes is that you are short-sighted and wear glasses. They were last checked about 18 months ago and your prescription adjusted slightly. There has been no trauma or injury. Apart from your ‘floater’ you are not aware of any visual problem. Your migraine auras generally consist of bright zigzag lines in your vision that disappear after 10–15 minutes: they are unlike what you experienced last night.

If ophthalmological review is suggested, say something like: ‘My office is really busy at the moment. Can it be delayed until next week?’

Ask what the doctor thinks is going on and (if referred) what the specialist will do. If surgery is mentioned, ask if you will need a general anaesthetic or, if not, whether it will hurt.

The following information is on your summary sheet:

  • Age

  • 57

  • Past medical history

  • Hypertension

  • Classic migraine

  • Medication

  • Perindopril 5 mg mane

  • Eletriptan (Relpax) 40 mg stat prn

  • Allergies

  • Nil known

  • Immunisations

  • Up-to-date

  • Social history

  • Married to Dorothy

  • Non-smoker

  • Occasional safe alcohol

  • Family history

  • Hypertension

  • Migraine.

SUGGESTED APPROACH TO THE CASE

The key tasks are to take ...

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