Additional History:
Upon further questioning, the patient reports difficulty remembering to take her anti-hypertensive medications. She also reports a history of exertional chest pain upon various physical activities such as climbing stairs too quickly. Chart review reveals she has been diagnosed with peripheral vascular disease for which she takes cilostazol. Family history reveals a mother with a history of STEMI at 52 and sister with hypertension.
Physical Exam:
General appearance: Woman in no apparent distress, appears her stated age
Vitals: Temp: 37C, BP: 164/92, HR: 92, RR 16
Best Corrected Visual Acuity (BCVA): OD 20/40, OS Count fingers at 2 feet
Pupils: Pupils equal and reactive to light OU, 1+rAPD OS
EOM: full OU
Confrontation Visual Fields (CVF): Full OU
Intraocular pressures (Tonopen in ED): OD 17 mmHg, OS mmHg
External ocular exam:
Eyelids: OU flat
Conjunctiva: OU white and quet
Cornea: OU Clear
Anterior Chamber: OU deep and quiet
Iris: OU round and reactive, no neovascularization of the iris (NVI) OU
Lens: 1-2+nuclear sclerosis OU
Gonioscopy: OU open to scleral spur, no NVI/NVA
Dilated fundus exam:
The right dilated fundus exam is WNL. Dilated fundus exam of the left eye reveals the following:
Above Image Courtesy of Jeanette Du, MD
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Ophtho On Call Case 8 Index
Ophtho On Call Case 8: Introduction