History Taking · Foundation · Ophthalmology

Painless Red Eye

Practise this PLAB 2 history taking station on Subconjunctival Haemorrhage. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in primary care. Mr Quentin Quinn, a 68-year-old man, has attended because he noticed his right eye became red overnight. The redness is painless and his vision is unaffected. Please take a history, examine him, and discuss the likely diagnosis and management.

Background notes: PMH: Occupational lung disease (mild, monitored), Hypertension, Hypercholesterolaemia, Presbyopia

What this station tests

  • Checking blood pressure: the commonest underlying cause of subconjunctival haemorrhage, and the clinical value of the consultation
  • Checking anticoagulation status: warfarin, DOACs, aspirin as contributing factors
  • Distinguishing from serious causes of red eye: glaucoma (pain, blurred vision), uveitis (photophobia), scleritis (deep pain)
  • Confident reassurance: it looks dramatic but resolves spontaneously in 1-2 weeks
  • Using the benign presentation to address the underlying hypertension management

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

A painless red eye with normal vision is benign until proven otherwise, but the candidate must check blood pressure and anticoagulation status. Mr Quinn is 68, noticed his right eye was red this morning. No pain, normal vision. His wife insisted he come. Open with: 'Mr Quinn, tell me what you noticed and how the eye feels.' This is a reassurance station, but the candidate must earn the right to reassure by excluding serious causes.

Core approach

Confirm the benign pattern. Bright red, well-demarcated area of blood under the conjunctiva. No pain. Vision completely normal. No discharge, no photophobia, no foreign body sensation. No trauma. This is a subconjunctival haemorrhage: a burst blood vessel under the surface of the eye.

The critical check: blood pressure. He has hypertension. Uncontrolled hypertension is the commonest underlying cause. Measure his BP today. If significantly elevated, this haemorrhage is a marker of inadequate BP control, not just a cosmetic issue.

Check anticoagulation and bleeding tendency. Is he on warfarin, a DOAC, or aspirin? (He has AF risk factors.) Has he had any recent nosebleeds, bruising, or bleeding from other sites? Any recent straining, coughing, or vomiting (Valsalva precipitants)? Any blood thinners including over-the-counter aspirin?

Distinguish from other causes of red eye. Acute glaucoma: severe pain, blurred vision, mid-dilated pupil (absent). Anterior uveitis: photophobia, pain, small pupil (absent). Conjunctivitis: discharge, bilateral (absent). Scleritis: deep pain (absent). All absent, confirming benign subconjunctival haemorrhage.

Closing and safety netting

Reassure confidently. 'Mr Quinn, this is a subconjunctival haemorrhage, which is a burst blood vessel under the surface of the eye. It looks dramatic but it is completely harmless and will resolve on its own in 1 to 2 weeks, changing colour like a bruise.' No treatment needed. Artificial tears if mildly uncomfortable.

Address the underlying cause. If BP is elevated: 'Your blood pressure is higher than it should be, and this may have contributed. We need to review your blood pressure medication.' This is the clinical value of the consultation beyond the eye. Safety net: 'If you develop eye pain, vision changes, or discharge, come back as those would suggest a different problem.' Follow-up for BP review if needed.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for subconjunctival haemorrhage. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1: Data Gathering, Technical and Assessment Skills (Primary focus)

Scores well: Benign pattern confirmed (painless, normal vision, no discharge). BP checked. Anticoagulation status checked. Valsalva precipitants asked. Serious red eye causes excluded.

Costs marks: Not checking BP. Not checking anticoagulation. Not excluding serious causes.

Domain 2: Clinical Management Skills (Secondary focus)

Scores well: Confident diagnosis with no treatment needed. BP reviewed if elevated. Artificial tears if uncomfortable. No unnecessary referral. Safety netting for pain or vision changes.

Costs marks: Unnecessary referral. Prescribing unnecessary treatment. Not addressing BP.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Confident reassurance that matches the benign diagnosis. Explaining the resolution timeline (1-2 weeks). Acknowledging his wife's concern. Using the visit constructively for BP.

Costs marks: Being overly cautious about a benign condition. Not reassuring. Making it seem more serious than it is.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Not checking blood pressure. A subconjunctival haemorrhage in a patient with hypertension is an opportunity to check BP control. Candidates who reassure and send him home without measuring BP miss the clinical lesson.
  2. Referring to ophthalmology. A painless red eye with normal vision, no discharge, and no other symptoms does not need specialist referral. Candidates who refer demonstrate over-investigation of a benign condition.
  3. Not distinguishing from serious red eye causes. The reassurance is only valid after excluding painful causes. Candidates who reassure without screening for pain, vision changes, and photophobia provide premature reassurance.

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

How should I structure the subconjunctival haemorrhage history in this PLAB 2 station?

A painless red eye with normal vision is benign until proven otherwise, but the candidate must check blood pressure and anticoagulation status. Mr Quinn is 68, noticed his right eye was red this morning. No pain, normal vision.

What are examiners marking in this subconjunctival haemorrhage station?

Marks are won for: Benign pattern confirmed (painless, normal vision, no discharge). BP checked. Anticoagulation status checked. Valsalva precipitants asked. Serious red eye causes excluded. Marks are lost for: Not checking BP. Not checking anticoagulation. Not excluding serious causes.

What is the most common mistake candidates make in this subconjunctival haemorrhage station?

Not checking blood pressure. A subconjunctival haemorrhage in a patient with hypertension is an opportunity to check BP control. Candidates who reassure and send him home without measuring BP miss the clinical lesson.

How do I prepare for this station if I have not managed subconjunctival haemorrhage in clinical practice?

Structure beats experience here. Focus on checking anticoagulation status: warfarin, DOACs, aspirin as contributing factors. Work through the consultation approach above, then rehearse it aloud under the 8-minute time pressure so the structure holds up in the exam.

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