Vitals: Temp: 36.8C, BP: 132/82, HR 64, RR 16, glucose fingerstick is 90 mg/dl
On external exam you see the following:
VA with correction: OD 20/50 (upon lifting of the right eyelid), OS 20/20
Pupils: OD mid-dilated pupil and nonreactive to light, OS round and reactive to light
Intraocular pressures (IOP) by tonopen in ED: 14 mmHg OU
Confrontation Visual Fields (CVF): visual fields intact to finger count OU
EOM: see image below:
External ocular exam continued:
Eyelids: complete ptosis of the Right upper eyelid, left eyelid appears within normal limits
Conjunctiva: white and quiet OU
Cornea: Clear OU
Anterior Chamber: Formed OU
Iris: flat OU
Lens: 1+NS cataracts OU
(see case 1 for more information on cataracts)
Remaining Neuro Exam: The remainder of the cranial nerves and neurologic examination are all normal.
Fundoscopic exam of both eyes is within normal limits.
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Neuro-oph Case 4 Index