Examination
Examination (3 wks post injury and eye repair)
Presentation, three weeks post injury and repair of left eye
Complaining of photophobia, bilateral eye pain, decreased vision and red eyes.
Appearance
- Child in severe pain and discomfort, assisted by parents as appears unable to open eyes.
- GCS 15/15
- Awake, alert, and co operative
Vitals
- Temperature: 38.0°C
- Blood pressure 120/74
- Heart rate 98
- Respiratory rate 35
General
- No pallor or jaundice
- No signs of dehydration
- Bilateral cervical lymphadenopathy
- No oedema
Head and Neck
Right Eye
- Red eye, tearing and photophobia
- On slit lamp examination large keratic precipitates and small depigmented nodules (Dalen-Fuchs nodules) seen on the retinal epithelium.
- Mild panuveitis (anterior and posterior chamber)
- Decreased visual acuity, 20/200
- Testing accommodation caused pain in the left eye
Left Eye
- Excessive swelling and pain
- Severe panuveitis
- Visual loss
Chest
- Trachea centrally located.
- Chest clear on auscultation
- No abnormalities detected
Cardiovascular
- No raised JVP
- Normally placed apex beat
- S1 and S2 heart sounds present, no murmurs.
- No abnormalities detected
Abdomen
- Not distended
- Soft and non tender
- Bowel sounds present
- No abnormalities detected
Neurological
- Higher function intact
- Normal level of consciousness
- Gait normal
- Power 5/5 globally
- Tone normal globally
- Reflexes 2/4 for both upper and lower limbs
Dermatological
- No rashes noted