Station Title & Timing

  • Title: Hypertensive Retinopathy & Systemic Hypertension
  • Duration: 10 Minutes (2 minutes reading time, 8 minutes performance)
  • Candidate Task: History taking, physical examination (simulated), and management/counselling.

Learning Objectives

  • Conduct a structured history of hypertension-related symptoms.
  • Interpret fundoscopic findings and communicate them using lay language.
  • Identify signs of “hypertensive emergency” (Papilledema).
  • Formulate a management plan including lifestyle and pharmacological steps.

Patient Profile

  • Name: Mr. Robert “Bob” Miller
  • Age: 54 years old
  • Gender: Male
  • Occupation: Long-haul truck driver
  • Social History: Smoker (15 pack-years), high-sodium diet (fast food on the road), sedentary.

Presenting Complaint

“I’ve been getting some dull headaches lately, and my vision has been a bit blurry, especially in my right eye. I haven’t seen a doctor in years.”

Contextual Information

  • HPC: Headaches are worse in the morning, occipital location. Blurred vision is gradual, not sudden. No flashes or floaters.
  • Past Medical History: Told he had “high-ish” blood pressure at a pharmacy screening 2 years ago; never followed up.
  • Medications: Occasional Ibuprofen for headaches. No regular meds.
  • Allergies: Nil.
  • Family History: Father died of a stroke at age 62.

Exam Instructions

Candidate Instructions

Bob is a 54-year-old truck driver who presents with a headache and blurred vision.

  1. Take a focused history.
  2. Perform a simulated fundoscopic examination (the examiner will provide you with images/findings upon request).
  3. Explain the diagnosis and your management plan to Bob.

Standardised Patient (SP) Instructions

  • Demeanour: Slightly anxious but cooperative. You are worried you might lose your heavy vehicle license.
  • Symptoms: Describe the headache as “heavy” and the vision as “smudgy.”
  • Key Trigger: If the doctor mentions “emergency” or “hospital,” ask: “Does this mean I’ll have to stop driving? I need to work.”
  • Knowledge: You don’t know what “retinopathy” means.

Examiner Instructions

  • When the candidate describes how they would perform fundoscopy, provide the Key Clinical Findings below.
  • Observe for patient-centered communication and use of Murtagh’s “Diagnostic Model.”

Key Clinical Findings

  • Vitals: BP 195/115 mmHg (High), HR 82 bpm (Regular), BMI 31.
  • Fundoscopy (Right Eye): * Vessels: Visible “silver wiring” (shiny, white appearance of arteries) and AV nicking (veins appear pinched where arteries cross).
    • Retina: A few cotton wool spots (fluffy white patches) and flame-shaped hemorrhages.
    • Optic Disc: The margins are blurred and indistinct; you cannot trace the edge of the disc with a pen (Papilledema).
  • Fundoscopy (Left Eye): Similar findings, though the disc margin is slightly clearer than the right.

Communication Triggers (Murtagh’s Approach)

  • Open-ended: “Tell me more about how these headaches are affecting your day-to-day life.”
  • Summarising: “So, to make sure I’ve got this right: you’ve had these morning headaches for a month, your vision is getting blurry, and your blood pressure hasn’t been checked in a long time. Is that correct?”
  • Breaking News: Use the “Warning Shot” technique: “Bob, I’ve found some changes in the back of your eye that explain your symptoms, but they are quite serious.”

Assessment & Marking Guide

DomainKey Performance Indicators
HistoryScreened for red flags (weakness, chest pain, confusion). Identified lifestyle risks (diet, smoking).
Physical ExamIdentified high BP. Requested fundoscopy. Correctly identified “Papilledema” and “Silver wiring.”
Clinical ReasoningRecognised this as a Hypertensive Emergency due to end-organ damage (eyes).
CommunicationExplained “Retinopathy” as “damage to the wallpaper of the eye.” Addressed driving concerns empathetically.
ManagementRecommended immediate hospital transfer/specialist review. Discussed long-term BP control.

Sample Answers / Model Performance

1. Explaining the Fundoscopy (The “Complete Package”)

“Bob, looking at the back of your eye, I can see that the high blood pressure has caused the blood vessels to become stiff—we call this ‘silver wiring.’ More importantly, the pressure is so high that the optic nerve at the back of your eye is starting to swell. This is why you can’t see clearly.”

2. Differentiating from Glaucoma (Internal Thought/Examiner Q&A)

  • Candidate: “In glaucoma, we see ‘cupping’ where the center of the disc is hollowed out. Here, we see the opposite: the disc is bulging forward and the edges are blurry, which confirms papilledema from high pressure.”

3. The Management Plan

“Because your blood pressure is very high and it is affecting your eyes, we cannot treat this with just a pill today. I need to refer you to the hospital immediately to lower your blood pressure safely and prevent any permanent damage or a stroke. We will also need to discuss your truck driving license requirements once you are stable.”