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
