Date of Consultation:
1 November 2024
58y/o female, now with sudden onset blurred vision in her right eye.
Medical History:
58y/o female
# Type 2 Diabetes Mellitus: Well-controlled with Metformin 500mg BD. No known complications. HbA1c 6.5% (latest blood results).
# Hypertension: Managed with Amlodipine 5mg OD. No known complications. BP 128/78 mmHg (latest reading).
# Allergies: Penicillin - causes rash.
Presenting Complaint:
Patient now presents with sudden onset blurred vision in her right eye, ongoing for approximately 3 days. She reports a sensation of a 'curtain coming down' over her vision. No associated pain, redness, or discharge. She denies any flashes or floaters. Vision is worse in dim light. No alleviating or exacerbating factors noted.
Social History:
Lives with husband. Non-smoker. Occasional alcohol use. Works as a retired teacher. No recent foreign travel or sick contacts.
Physical Examination:
1. Visual Acuity Assessment:
- Distance Visual Acuity: Right eye 6/36, Left eye 6/9
- Near Visual Acuity: Right eye N18, Left eye N6
2. Colour Vision Assessment:
Ishihara plates: Right eye impaired, Left eye normal
3. Visual Field Assessment:
- Peripheral Visual Fields: Right eye constricted inferiorly, Left eye full to confrontation
- Blind Spot Assessment: Right eye enlarged, Left eye normal
4. External Eye Examination:
- General Inspection: No obvious swelling or erythema.
- Eyelid Assessment: Normal position, no ptosis or lagophthalmos.
- Conjunctival Assessment: Clear and white, no injection or discharge.
- Corneal Assessment: Clear, no opacities or abrasions.
- Anterior Chamber: Deep and clear.
5. Pupillary Assessment:
- Pupil Size and Symmetry: Pupils are equal and round, 3mm in diameter.
- Pupil Shape and Colour: Round, black.
6. Pupillary Reflexes:
- Direct Light Reflex: Right eye sluggish, Left eye brisk.
- Consensual Light Reflex: Right eye sluggish, Left eye brisk.
- Swinging Light Test: Right eye reveals a relative afferent pupillary defect (RAPD).
7. Ocular Motility Assessment:
- Strabismus Assessment: No strabismus noted.
- Eye Movement Testing: Full range of extraocular movements, no pain or diplopia.
- Nystagmus: No nystagmus present.
8. Fundoscopy:
- Fundal Reflex: Right eye dull, Left eye bright.
- Optic Disc Assessment: Right eye optic disc appears pale and swollen, cup-to-disc ratio obscured. Left eye optic disc sharp margins, C/D 0.3.
- Retinal Assessment: Right eye exhibits retinal haemorrhages and exudates, particularly in the superior temporal quadrant. Left eye retina appears healthy.
- Macular Assessment: Right eye macular oedema present. Left eye macula appears healthy.
9. Fluorescent Staining:
No corneal staining noted in either eye.
Clinical Impression:
Acute vision loss in the right eye, likely due to central retinal vein occlusion given the sudden onset, 'curtain' sensation, reduced visual acuity, RAPD, optic disc oedema, and retinal haemorrhages/exudates.
Management:
Treatment initiated:
- Advice to keep head elevated to reduce intraocular pressure (acute).
Further referrals or investigations:
Urgent referral to Ophthalmology for further assessment and management. Consider urgent blood tests including FBC, ESR, CRP, and a fasting lipid profile to investigate underlying causes.
Date of Consultation:
[Insert date of consultation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Insert patient age in years]y/o [Insert male or female], now with [Insert acute issues or most important issue]. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Medical History:
[Insert patient age in years]y/o [Insert male or female] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
# [Insert medical comorbidity]: [Insert control status][insert medications][insert known complications][insert latest blood results]. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Add one comorbidity or past surgery per line.)
# Allergies: [Insert specific allergy and severity] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Presenting Complaint:
Patient now presents with [Insert presenting complaint described clinically in the following order: issue, duration, associated issues, important negatives, alleviating or exacerbating factors]. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Social History:
[Insert relevant social history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Physical Examination:
1. Visual Acuity Assessment:
- Distance Visual Acuity: [Insert distance visual acuity] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Near Visual Acuity: [Insert near visual acuity] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Additional Visual Acuity Testing: [Insert additional testing such as counting fingers, hand movements, or light perception] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
2. Colour Vision Assessment:
[Insert colour vision assessment result] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
3. Visual Field Assessment:
- Peripheral Visual Fields: [Insert peripheral visual field findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Blind Spot Assessment: [Insert blind spot findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Visual Field Defects: [Insert specific visual field defects] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
4. External Eye Examination:
- General Inspection: [Insert general inspection findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Eyelid Assessment: [Insert eyelid findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Conjunctival Assessment: [Insert conjunctival findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Corneal Assessment: [Insert corneal findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Anterior Chamber: [Insert anterior chamber findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
5. Pupillary Assessment:
- Pupil Size and Symmetry: [Insert pupil size and symmetry findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Pupil Shape and Colour: [Insert pupil shape or colour findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
6. Pupillary Reflexes:
- Direct Light Reflex: [Insert direct light reflex findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Consensual Light Reflex: [Insert consensual light reflex findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Swinging Light Test: [Insert swinging light test findings and RAPD if present] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Accommodation Reflex: [Insert accommodation reflex findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
7. Ocular Motility Assessment:
- Strabismus Assessment: [Insert strabismus findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Eye Movement Testing: [Insert eye movement findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Nystagmus: [Insert nystagmus findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
8. Fundoscopy:
- Fundal Reflex: [Insert fundal reflex findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Optic Disc Assessment: [Insert optic disc findings including cup-to-disc ratio] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Retinal Assessment: [Insert retinal findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Macular Assessment: [Insert macular findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
9. Fluorescent Staining:
[Insert fluorescent staining findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Clinical Impression:
[Insert clinical impression summarising key findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Management:
Treatment initiated:
- [Insert treatment or medication initiated, labelled as acute or chronic if stated] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Further referrals or investigations:
[Insert further referrals or investigations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(For each section, only include information if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the section entirely. Never add direct quotations. Never come up with your own patient details, diagnoses, interpretations, treatments, or plans. Use only the transcript, contextual notes or clinical note as the source of truth. Never hallucinate.)
