Patient History, Chief Complaint, and Risk Factor Assessment
The history and risk-factor domain tests whether you can convert a patient's words into a prioritized differential and an urgency level. Part II presents realistic complaints; the marks sit in the follow-up questions you choose and the red flags you recognize, not in the final diagnosis alone.
Build the complaint systematically
Use a fixed framework so nothing is skipped: onset (sudden vs gradual), laterality (monocular symptoms are never refractive or cortical), duration and frequency, character (burning, foreign body, deep ache, pressure), aggravating and relieving factors, associated symptoms (photophobia, discharge, flashes, floaters, halos, diplopia, jaw claudication), and timing (morning vs evening, positional). Convert "blurry vision" into monocular versus binocular, constant versus transient, and distance versus near.
Risk factors that change management
Duration of diabetes and HbA1c; axial myopia for retinal detachment; smoking and family history for AMD; age, Black ancestry, family history, thin central cornea, and steroid use for glaucoma; carotid or cardiac disease for embolic transient monocular vision loss; age over 50 with headache, scalp tenderness, or jaw claudication for giant cell arteritis. Reconcile the medication list - hydroxychloroquine, ethambutol, amiodarone, topiramate, tamsulosin, and chronic topical steroids all generate examination findings.
Worked example
A 62-year-old man reports a gray "shade" descending over the right eye, lasting three to five minutes, twice this week. It is monocular, painless, and resolves completely. He has a 40-pack-year smoking history and a carotid bruit. Reasoning: transient, altitudinal, monocular loss in a vascular-risk patient is amaurosis fugax until proven otherwise - an embolic event from the ipsilateral carotid. Same-day referral for carotid imaging and stroke evaluation, not a dry-eye trial. A bilateral shimmering zigzag spectrum with headache would point to migraine aura instead.
Traps
Attributing transient visual loss to dry eye because the exam is quiet; forgetting to ask about monocular versus binocular symptoms; missing giant cell arteritis symptoms in an elderly patient with visual complaints; and recording "no complaints" without documenting a systems review.