History of Present Illness (HPI)
A 68-year-old woman with a history of non–insulin-dependent diabetes mellitus type 2, rheumatoid arthritis, and scleritis left eye (OS) complains of increasing pain and redness in her OS. Her scleritis has been difficult to control in the past, and last year the dosing of adalimumab was increased from 40 mg subcutaneous (SC) every 2 weeks to every week. She had to discontinue adalimumab 3 weeks ago because of an ulcer in her foot, as per the recommendations of her rheumatologist and primary care physician. Shortly after that, she reports the OS became very painful and red. She rates the pain as 8 to 9 out of 10. Her vision is a bit blurry, but she denies any major change.
Eye-Related Medications
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Ibuprofen 800 mg by mouth (PO) three times a day (TID)
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Adalimumab 40 mg SC every week (held as of 3 weeks ago)
| OD | OS | |
|---|---|---|
| Vision | 20/25 | 20/40 |
| Intraocular pressure (IOP) | 14 | 14 |
| Lids and lashes: | Normal | Normal |
| Sclera/conjunctiva: | White and quiet | See Fig. 16.1 |
| Cornea: | Clear | Clear |
| Anterior chamber (AC): | Deep and quiet | Deep and quiet |
| Iris: | Flat | Flat |
| Lens: | 1+ nuclear sclerosis (NS) | 2+ NS 1+ posterior subcapsular cataract (PSC) |
| Anterior vitreous: | Clear | Clear |
| Dilated fundus examination (DFE): | Deferred |
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