Question

Please Write Succinct: Vision Loss

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• Review of Systems: Associated symptoms and Risk Factors
• Findings on Focused Physical Ex
• Five Differential Diagnosis

See example below for question #1:

1. Sore Throat

ROS:

Associated symptoms: fever, redness or eye discomfort, sneezing, wheezing, cough, runny nose, postnasal drip, GERD like symptoms, fatigue, muscle ache, n/v, and diarrhea.

Risk Factors:

Smoking, new sexual partners, irritant exposure, medications, and chronic health problems.

Red flags:

drooling, unable to swallow, unable to lie down, restless, unable to stay still, and unable to talk.

PE findings:

Epiglottis- severe illness with signs of upper airway obstruction such as restlessness, stridor, difficulty breathing, drooling, inability to swallow and high fever signals epiglottis and requires immediate referral. Further examination with a tongue blade could trigger laryngospasms and lead to airway obstruction.

Peritonsillar retropharyngeal abscess- orthopnea, dyspnea, symmetrical swelling, abscess, trismus.

Viral pharyngitis: Erythema, edema of throat, tender posterior cervical nodes.

GAS: temp more than 101.5, exudate anterior cervical lymphadenopathy.

Mononucleosis: presence or absence of pharyngeal exudate, posterior cervical lymphadenopathy, splenomegaly.

Gonococcal pharyngitis: pharyngeal exudate bilateral cervical lymphadenopathy

Inflammation: sinus tenderness, pale or swollen pharynx, postnasal drainage visible, no fever or lymphadenopathy.

Aphthous Stomatitis: shallow ulcers, no vesicles; indurated papules that progress to 1 cm ulcers; ulcer has yellow membrane and red halo; no fever or nodes.

Herpes simplex Lesions: perioral lesions; lymph adenitis; vesicles on palate, pharynx gingiva.

Herpetic pharyngitis: vesicles, ulcers, or exudate of the oral and pharyngeal mucosa.

Candidiasis: curd like white plaques that bleed when scraped off.

Differential diagnosis:

Viral Pharyngitis, Streptococcal Pharyngitis, peritonsillar or retropharyngeal abscess, Mononucleosis, Epiglottis, gonococcal pharyngitis, Herpangina, Vincent angina, Aphthous stomatitis, HSV type 1, Candidiasis, GERD.

Answer 1

Associated symptoms:– cloudy vision, tunnel vision, double vision, headache, chronic eye redness, inability to see shapes, poor night vision, lacrimation.

Risk factors:– Age, diabetes, infection, injury, recent eye surgery, intraocular pressure, age related occular problem like cataract, glaucoma, macular degeneration.

PE findings:–

Glaucoma – Eyeball: Tenderness present.
Eyelids: Marked edema with narrowing of
the palpebral aperture.
Conjunctiva: Both ciliary and conjuntival congestion with chemosis.
Cornea: Steamy and insensitive.
Anterior chamber: Very shallow, cells
and flare may be present [but no keratic precipitates (KPs)].
Iris: Pattern is lost and discolored.
Pupil: Mid-dilated and vertically oval. Reaction to light and accommodation are absent.
IOP: Markedly elevated.
Visual acuity: It may be reduced to percep-
tion of light (PL) and projection of rays (PR).

Cataract – Vision: It may be reduced to hand movements in dense opacity.
Color of the lens: It is yellow, brown or
black (better appreciated in dilated pupil).
Iris shadow: Usually present.
Slit-lamp grading of the hardness of the
nucleus can be judged by the pigmenta-
tion of the nucleus.

Optic neuritis –  Visual acuity may be 6/60 or even less, although some patients have only mild loss of vision (6/12).
Presence of local tenderness, especially
near the site of attachment of superior
rectus tendon.
Pupillary reactions may be: Sluggish and ill-sustained. Relative afferent pupillary defect (Marcus-Gunn’s pupil).
Impaired colored vision.
A delayed dark adaptation.
Field of vision—central, centrocecal or
paracentral scotoma

Age related macular degeneration – They appear as small, discrete, yellow-white, slightly elevated spots at the posterior poles of both fundi. With advancing age they increase in size and number.
Secondary calcification in long-standing lesions gives them a glistening-white appearance.

Diabetic retinopathy – Microaneurysms, dot and blot haemorrhages, flame shaped haemorrhages, retinal oedema with hard exudate, cotton wool spot, macular oedema.

Differential diagnosis:- Glaucoma, cataract, age related macular degeneration, optic neuritis, diabetic retinopathy.