History of Present Illness (HPI)
A 24-year-old jazz musician noticed poor vision, both eyes (OU), about 3 months ago. He has not been feeling well recently, but attributed that to his odd hours of work and little sleep. He has no history of vision problems, although he was hit in his left eye (OS) as a child and required stitches to close his skin wound. His weight has recently decreased even though his appetite has not changed and he admitted to iv drug use.
| OD | OS | |
|---|---|---|
| Visual acuity | 20/60 | 20/400 |
| Intraocular pressure (IOP) (mm Hg) | 12 | 11 |
| Sclera/conjunctiva | Clear. No injection | Clear. No injection |
| Cornea | Clear | Clear |
| Anterior chamber (AC) | No cell or flare | No cell or flare |
| Iris | Within normal limits (WNL) – no posterior synechiae | WNL – no posterior synechiae |
| Lens | Clear | Clear |
| Vitreous cavity | Trace vitreous cells | Trace vitreous cells |
| Retina/optic nerve | Multifocal retinal whitening/necrosis of outer retina ( Fig. 48.1 ) | Multifocal retinal whitening/necrosis of outer retina; mottling of RPE; pallor of optic nerve ( Fig. 48.2 ) |
Questions to Ask
- •
Has your vision changed in the past month?
- •
Have you seen a doctor recently to find out why you have not been feeling well?
- •
Because you work in jazz clubs, did you ever participate in drug use or unprotected sex with women and/or men?
- •
Do you have redness, pain, photophobia, or floaters in either eye?
The patient reports that he started to notice changes in vision 3 months ago, but only recently has it gotten so bad that he is having difficulty reading music sheets. He has an appointment to see a family doctor in 2 weeks but has not sought medical care until now. Occasionally, he injects heroin intravenously (IV) and does have unprotected sex with several of the women waitresses and women bartenders. He reports his eyes feel fine except that the vision is blurred, particularly in the OS. He reports no pain, redness, light sensitivity, or floaters in either eye.
