On further questioning, he denies headache, jaw claudication, or recent weight loss. He reports a change to his hypertensive medication routine to a night-time dose as it was easier for him to remember right before bed. Chart review reveals a TIA of the middle cerebral artery that resolved after 4 hours without further intervention. His medications include metformin, aspirin, rosuvastatin, lisinopril, and AREDS2 vitamins. Family history reveals that his brother died at 65 of cerebrovascular disease related complications and his father with poorly-controlled Type 2 diabetes. His mother’s history is unknown.
General appearance: Well-appearing and in no apparent distress.
Vitals: Temp: 37C, BP: 140/85, HR: 77, RR 16, BMI 29
Best Corrected Visual Acuity (BCVA): OD 20/25, OS 20/200
Pupils: Pupils equal and reactive to light OU, 3+rAPD OS
EOM: full OU
Intraocular pressures (Tonopen in ED): OD 17 mmHg, OS 15 mmHg
External ocular exam:
Eyelids: flat OU, no ptosis OU
Conjunctiva: white and quiet, anicteric OU
Cornea: Clear OU
Anterior Chamber: Deep and quiet OU
Iris: Round and reactive OU
Lens: 1+nuclear sclerosis OU
Fundoscopic exam of the right eye is within normal limits, while fundoscopic exam of the left eye reveals the following:
Above Image Credit: Kyle Hirabayashi, MD
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Ophtho On Call Case 1 Index
Ophtho On Call Case 1: Introduction