History of Present Illness
A 27-year-old woman with no significant past ocular history or medical history complains of new floaters in the left eye (OS) for 3 days. She states her vision is also blurred in this eye. She has no complaints in the other eye.
Exam
| OD | OS | |
|---|---|---|
| Vision: | 20/20 | 20/30− |
| Intraocular pressure (IOP): | 11 | 19 |
| Lids and lashes: | Normal | Normal |
| Sclera/conjunctiva: | White and quiet | White and quiet |
| Cornea: | Clear | Clear |
| Anterior chamber (AC): | Deep and quiet | 1+ cells |
| Iris: | Flat | Flat |
| Lens: | Clear | Clear |
| Anterior vitreous: | Clear | 1+ anterior vitreous cells |
Dilated fundus examination (DFE) (See Fig. 49.1 )
| Nerve: | Cup-to-disc (c/d) 0.2, pink, sharp |
| Macula: | Normal |
| Vessels: | Normal caliber and course |
| Periphery: | Unremarkable |
Further Questions to Ask
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Have you ever experienced anything like this before?
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Do you live with any pets?
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Have you traveled internationally recently?
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Have you eaten any uncooked or poorly cooked meat recently?
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Do you have any problems with your immune system?
She did used to live with a cat at one time. Otherwise, she answers no to the questions.
