Case 2: Physical Exam

Case 2 Index
Physical exam

Vital Signs: BP 125/78, HR 81, T 36.6 (97.8F), RR 10, SpO2 = 98%, BMI 25.7

General Appearance: Well-appearing female in no distress
HEENT: No ocular inflammation. Temporal arteries are nontender with a palpable pulse bilaterally.
Lymph: No lymphadenopathy.
Cardiovascular: No murmurs, rubs, or gallops. No carotid bruits. Radial, brachial, dorsalis pedis, and posterior tibialis pulses were 2+.
Pulmonary: lungs clear to auscultation bilaterally.
Abdominal: bowel sounds present, soft, nontender, nondistended, no hepatomegaly, no splenomegaly
Extremities: warm and well perfused extremities, no pitting edema.
Neurologic: alert and oriented x3. No light perception in the left eye. No other focal deficits noted.
Psychiatric: Calm, pleasant
Skin: No rashes or purpura.

Retinal exam: evidence of anterior ischemic optic neuropathy OS

Cogan, D.G. “Ischemic Optic Neuropathy”. Neuro-Ophthalmology Virtual Education Library: NOVEL Web Site. Click image to go to link.

What’s at the top of your differential diagnosis in this patient? Choose 3 before moving on!
Atherosclerotic plaque rupture
Cranial Giant Cell Arteritis
Thromboembolic phenomenon from occult atrial fibrillation
Septic emboli of infective endocarditis
Viral polyarthritis
Multiple Sclerosis
Systemic Lupus erythematosus
Relapsing Polychondritis
Hypertensive retinopathy

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Case 2 Index
Case 2 Introduction
Case 2 Review of Systems