History of Present Illness (HPI)
A 51-year-old man with a history of cutaneous T-cell lymphoma (mycosis fungoides) complains of severe loss of vision in his right eye (OD). It is difficult for him to speak and provide a history because of significant pain in his mouth. He has ulcers on his tongue and is being treated for oral candidiasis with fluconazole ( Fig. 70.1 ). Details are limited, but he is able to communicate that it has been getting worse over the course of the last 3 weeks or so. He denies eye pain ( Fig. 70.2 ).
| OD | OS | |
|---|---|---|
| Vision | Count fingers 3′ | 20/25 |
| Intraocular pressure (IOP) | 20 | 16 |
| Lids and lashes: | Normal | Normal |
| Sclera/conjunctiva: | White and quiet | White and quiet |
| Cornea: | Clear | Clear |
| AC: | 2+ white cells | Deep and quiet |
| Iris: | Flat | Flat |
| Lens: | Clear | Clear |
| Anterior vitreous: | 2+ white cells | Clear |
| Nerve: | Cup-to-disc (c/d) 0.3, pink, sharp |
| Macula: | Flat |
| Vessels: | Normal caliber and course |
| Periphery: | Unremarkable |
Further Questions to Ask
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Besides oral candidiasis, have you been treated for any other infections lately?
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Any recent hospitalizations? How do you feel right now? Any malaise, night sweats, or chills?
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Do you have any indwelling hardware?
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What treatment have you had for your cancer?
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Are you on medications that suppress your immune system, like steroids or chemotherapy?
The patient answers no to all of the questions. He has generally had an increased level of fatigue and depressed mood since his cancer diagnosis, but no recent changes. He denies any recent steroids but knows he has been treated with them in the past. The only specific treatment he recalls for his cancer is interferon-alpha, but he is otherwise unsure.
Optical coherence tomography was performed to better characterize the extent of retinal involvement ( Fig. 70.3 ).
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