General appearance: Well appearing and in no respiratory distress
Vitals: Temp: 37C, BP: 102/60, HR: 100, RR 24, O2 sat: 99%, Weight: 31 lb 6 oz, Height: 2 feet, 10 inches
Visual acuity: OD 20/80, OS 20/30
Pupils: OD Equal and reactive to light OU, no rAPD OU
EOM: full OU, no nystagmus OU
Intraocular pressures (IOP): Soft to palpation OU
External Eye Exam: Conjunctiva quiet, no injection OU, Cornea is clear OU, good red reflex OU with direct ophthalmoscope
Below is an image of the patient’s external eye exam:
Above Image Courtesy of Dr. Thomas Quehl
Because of the above findings, the patient is referred for pediatric ophthalmology evaluation.
Click here for the answer and for the exam at the ophthalmology visit!
Peds ophtho Case 2 Index
Peds Ophtho Case 2 Introduction
Peds Ophtho Case 2 Additional History