Chief Complaint: Blurry vision OS
Location: OS
Severity: Sever
Duration: 2 weeks
Relieving Factors: none
Patient Ocular History: First eye exam with no previous ocular Hx.
Family Ocular History: Unremakrable
Patient Medical History: Mild HTN and type 2 Diabetes since 2008.
Family Medical History: Non-contributory
Review of Systems: unremarkable
Clinical Finding:
Location: OS
Severity: Sever
Duration: 2 weeks
Relieving Factors: none
Patient Ocular History: First eye exam with no previous ocular Hx.
Family Ocular History: Unremakrable
Patient Medical History: Mild HTN and type 2 Diabetes since 2008.
Family Medical History: Non-contributory
Review of Systems: unremarkable
Clinical Finding:
- BCVA: 20/20 OD, 20/200 OS
- EOM: Normal
- Pupils: Mild APD OS
- Conf Fields: Full OD, Restricted OS
- IOP: 15mmHg OU with applination
- Slit Lamp: Small Corneal scars OU secondary to weld splatter.
- BP: 118/79mmHg in office
- Pulse: 67 bpm
- Dilated exam: See Photos
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| Retina OD |
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| Retina OS |
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| OCT OS |
The assessment and plan are located in the comments section.
Assessment: CRVO OS
ReplyDeletePlan: Refer patient to PCP for blood work. Monitor condition in 2 weeks.
Notes: Patient returned in 2 weeks and VA had improved OS to 20/40--. Over the course of the next month he continued to improve and there were no signs of ischemia at 3 months.