you will perform a history of a head ear or eye problem that your instructor has provided
You will perform a history of a head, ear, or eye problem that your instructor has provided you or one that you have experienced and perform an assessment including head, ears, and eyes. You will document your findings, note any abnormal findings, and submit this in a Word document to the drop box provided.
Eye Patient
The patient is a 51 year-old stay-at-home mother who presented to the ED with severe R brow, R cheek and R eye pain/pressure that started 2-3 hrs prior. She also noticed blurry vision from that eye and rainbow-colored halos around lights around the same time. Accompanying symptoms include acute nausea. She has vomited twice since feeling the eye pain. Denies prior episodes. Denies flashes, floaters or diplopia. There is mild redness in the R eye.
Past Ocular History:
Hx myopia OU
No prior eye surgeries, trauma, amblyopia or strabismus
Ocular Medications:
None
Past Medical History:
Degenerative disc disease – lower back
Surgical History:
None
Past Family Ocular History:
Father: chronic angle closure glaucoma
No FHx of macular degeneration or other blinding diseases.
Social History:
30 pack year smoking history
Drinks alcohol on occasion
No illicit drug use
Medications:
Multivitamins
Vicodin prn (uses few days/month for back pain)
Allergies:
None
ROS:
Denies recent illnesses, new medications, CNS, lungs, GI, skin, joint problems except for above.
Ocular Exam
Visual Acuity (cc):
OD: 20/70
OS: 20/20
