Case Study3

CHIEF COMPLAINT: "My eye is red and burning." History of Present Illness:

Mr. E. is a 55-year-old machinist who comes to your office complaining of pain in his right eye for the past 24 hours. He describes the pain as severe, aching, and deep; he has noticed a decline in his vision. He does not wear corrective lenses. He denies any work-related exposures. He denies any upper respiratory infection or allergies. He has a history of hypertension and sees his physician regularly for checkups; he has been told that his blood pressure is controlled on his medication. He has not experienced nausea, vomiting, diaphoresis, or abdominal pain.

Mr. E. has smoked three packs of cigarettes daily for 40 years. He has never had surgery.

What parts of the exam would you like to perform? (Circle the appropriate areas.)

General Survey Breasts and Axillae

Vital Signs Female Genitalia

Skin Male Genitalia

Head and Neck Anus, Rectum, and Prostate

Thorax and Lungs Peripheral Vascular/ Extremities

Cardiovascular Musculoskeletal

Abdomen Nervous System

What physical findings are you looking for to help determine the diagnosis?

These are the actual findings on physical examination:

General Survey

Vital Signs

Skin HEENT

Alert, muscular, middle-aged man sitting on the examining table, holding his head in moderate discomfort

BP 160/95 mm Hg; HR 90 bpm and regular; respiratory rate 12 breaths/min; temperature 98.4°F

No rash; nails without clubbing or cyanosis

Normocephalic, atraumatic

Visual acuity is measured at 20/100 in the right eye (O.D.) and 20/20 in the left eye (O.S.); the right pupil is dilated and fixed; the cornea appears cloudy; the right fundus is difficult to visualize External ear canals patent, tympanic membranes with good cone of light

Sinuses nontender

Oral mucosa pink; dentition good; pharynx is without exudates

Supple, without thyromegaly; no cervical or supraclavicular adenopathy

Thorax symmetric, with increased AP diameter and slight hyperresonance over both lung fields

Breath sounds resonant; no wheezes or rhonchi

JVP 6 cm above right atrium; carotid upstrokes brisk, without bruits

PMI tapping and nondisplaced

Good Si, S2; no S3 , S4; no murmurs, rubs, or clicks

Based on this information, what is your differential diagnosis?

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Blood Pressure Health

Blood Pressure Health

Your heart pumps blood throughout your body using a network of tubing called arteries and capillaries which return the blood back to your heart via your veins. Blood pressure is the force of the blood pushing against the walls of your arteries as your heart beats.Learn more...

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