Historical past and Bodily Examination:

Chief Grievance: Sudden lower of imaginative and prescient within the left eye.

Historical past of Current Sickness (HPI): Jessica is a 32-year-old math instructor who presents to the emergency room with a good friend for analysis of sudden lower of imaginative and prescient within the left eye. She denies any trauma or harm. The signs began this morning when she awoke and have progressively worsened over the previous few hours. She had some blurring of her imaginative and prescient 1 month in the past and thinks that will have been associated to getting overheated, because it improved when she was in a position to get in a cool, air-conditioned setting. She has some ache if she tries to maneuver her eye, however none when she simply rests. She can be unable to find out colours. She denies tearing or redness or publicity to any chemical substances. Nothing has made it higher or worse.

Previous Medical Historical past (PMH): Jessica is often wholesome. She had chickenpox at age 10 and a tonsillectomy/adenoidectomy at age 11. She has no medical issues. She has by no means been hospitalized. She has 4 kids, all spontaneous vaginal deliveries.

Household Historical past (FH): Jessica’s father has a coronary artery illness (he had a stent positioned at age 67) and a mom with hypertension.

Social Historical past (SH): Jessica stop smoking 10 years in the past (two packs day by day for five years); she drinks an occasional wine cooler, and she or he denies illicit drug use. She works as a math instructor.

Drugs: None reported.

Allergy symptoms: None reported.

Assessment of Methods (ROS):

Constitutional: Denies fever, chills, night time sweats, weight reduction, or fatigue.

Eyes: Decreased imaginative and prescient and unable to find out colours within the left eye.

Ears, Nostril, Throat: No adjustments in listening to, sore throat, nasal or sinus congestion.

Cardiovascular: No chest ache or palpitations.

Respiratory: No shortness of breath or cough.

Gastrointestinal: No belly ache, diarrhea, or constipation.

Genitourinary: No dysuria or vaginal discharge.

Musculoskeletal: No neck ache or stiffness, swelling within the legs.

Neurological: No headache.

Pores and skin: No rash or lesions.

Bodily Examination:

Normal: Affected person is alert; she seems anxious.

Very important Indicators: BP 135/85 mm Hg; HR 64 bpm and common, RR 16 per minute, T: 98.5F.

Head and Neck: Visible acuity 20/200 within the left eye and 20/30 in the proper eye. Sclera white, conjunctivae clear. Unable to evaluate visible fields within the left aspect; visible fields on the proper eye are intact. Pupil response to mild is diminished within the left eye and brisk in the proper eye. The optic disc is swollen. No neck stiffness.

Chest: Clear to auscultation bilaterally. No wheezes or rhonchi.

Cardiovascular: Common rhythm with no murmurs, rubs or gallops. No peripheral edema.

Stomach: Delicate and non-tender. No hepatosplenomegaly or plenty palpated.

Extremities: Full vary of motions; no swelling or deformity.

Neurological: Psychological standing: Oriented x 3. Cranial nerves: I-XII intact; horizontal nystagmus is current. Muscle mass with regular bulk and tone; Regular finger to nostril, adverse Romberg. Intact to temperature, vibration, and two-point discrimination in higher and decrease extremities. Reflexes: 2+ and symmetric in biceps, triceps, brachioradialis, patellar, and Achiles tendons; no Bab

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