Personal Details:
Name: Mrs Carter
Age: 54
Medical Record:
Past medical history: Polymyalgia Rheumatica (PMR) for 2 years.
Regular medication: Prednisolone (2mg), previous weaning trial failed.
Notes:
A 54-year-old woman presents with a 3-month history of blurred vision and seeing floaters in both eyes. She also reports some mild eye pain for the last few days.
She is on long-term prednisolone for PMR.
•Task:
1. Take a focused history of her visual symptoms and perform a relevant examination.
2. Discuss the likely diagnosis and management plan.
Opening Sentence: “Doctor, I’m getting worried about my eyes. Everything seems a bit blurry, and I keep seeing these little black specks floating around.”
Open History (to give freely): “It’s been going on for about three months now, in both eyes. I’ve never worn glasses before. The last few days, my eyes have started to feel a bit achy as well. It’s not a bad pain, just a dull ache.”
ICE (Ideas, Concerns, Expectations):
Ideas: “I thought I just needed glasses, but now that my eyes are aching, I’m not so sure.”
Concerns: “What’s going on? Will my vision improve? Am I going blind?”
Expectation: “I want to know what’s wrong and what can be done about it.”
How to Act: You are a sensible woman, but you are now becoming anxious about your vision.
More History (only if asked): Your vision has been getting blurry and worse. You have no headaches, no redness, and no discharge from your eyes. You live alone. You work as a pet manager.
Social History: Lives alone.
Questions to ask:
“What are cataracts and glaucoma?”
“Do I have to stop my steroids?”
Examination: (visual acuity, fundoscopy) to be given to the candidate when he verbalises that he wants to examine the patient:
Whitish bilateral lens (suggest cataract) with reduced visual acuity bilaterally and also mild early papilledema bilaterally
History of Presenting Complaint:
You’ve noticed your vision getting worse. Is it in one eye or both?
Can you describe the change? Is it blurry? Have you lost any part of your vision?
You mentioned glare from headlights. Can you tell me more about that?"
Have you had any pain in your eyes or any headaches?
Review of Underlying Condition & Medication:
You’ve been on Prednisolone for two years for your PMR. What dose did you start on, and what dose are you on now?
How is the PMR at the moment? Any stiffness or pain?
Red Flag Screening (for Giant Cell Arteritis - GCA):
I know your PMR is stable, but I have to ask: have you had any new headaches, any pain in your scalp when you brush your hair, or any pain in your jaw when you chew?
ICE (Ideas, Concerns, Expectations):
You thought this might be related to the steroids. What did you know about their side effects on the eyes?
What is your biggest worry? Is it about your eyesight or about your PMR?
What were you hoping I could do for you today?
Explain the situation, the likely diagnosis or DD:
Thank you for coming in. It’s very important to get any changes in your vision checked out, especially when you are on long-term steroid treatment.
(After examination, which would include visual acuity, fundoscopy, and checking eye pressures if possible)
Based on your symptoms and the fact that you are on long-term prednisolone, I am concerned about two possible side effects of the steroids on your eyes. The blurred vision and floaters could be caused by the development of cataracts, which is a clouding of the lens inside the eye. The recent onset of pain is more worrying, as it could be a sign of glaucoma, which is a build-up of pressure inside the eye.
Addressing and answering the patient’s ICE:
You’re asking what these conditions are and if you’re going blind. Let me reassure you, both cataracts and glaucoma are treatable conditions, but it is crucial that we get you seen by a specialist urgently to prevent any permanent damage to your vision. Long-term steroid use is a well-known cause of both of these conditions.
Next Steps:
I am going to make an urgent referral for you to be seen by an ophthalmologist, an eye specialist, at the hospital. They need to see you within the next day or two to measure the pressure in your eyes accurately and have a detailed look at the lenses. You must not stop taking your prednisolone, as that could cause your polymyalgia to flare up badly. The eye specialist will manage your eye problems, and we will manage your steroids.”
The treatment for cataracts is a very common and successful operation to replace the cloudy lens. The treatment for glaucoma usually starts with eye drops to lower the pressure in the eye. The specialist will discuss all the options with you.”
Addressing ideas, concerns, and expectations: Explain the likely diagnoses (steroid-induced cataracts and glaucoma) in simple terms. Reassure her that they are treatable but require urgent attention.
The key action is an immediate, urgent referral to ophthalmology. The candidate should demonstrate they understand the urgency by stating they will call the on-call ophthalmologist. They must also give the crucial safety-netting advice not to stop the steroids abruptly.
What is scenario testing? This case tests the candidate’s knowledge of the significant ocular side effects of long-term steroid use. It also tests their ability to recognise a red flag symptom (eye pain) and initiate an appropriate urgent referral.
The safety-netting advice regarding not stopping the steroids is a critical part of the management.