Consultation
HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old white male that was admitted to the emergency room at Hospital for complaints of sudden loss of vision of his right eye yesterday. Patient reported that he was bending over and cleaning a garbage can when he noticed his vision blacked out. The patient reports that the vision did come back in approximately a half hour. The patient had a previous episode of ischemic optic neuropathy last month where he lost total vision and remains totally blind in his left eye to date. This occurred approximately 1 month ago. It was recommended to the patient that he follow up in the emergency room for a sed rate and C-reactive protein. Patient’s initial testing 1 month ago resulted in minimally elevated sed rate and C-reactive protein. It was recommended to the primary care that these tests be repeated, but she claimed that consultation with a rheumatologist that she did not think that it was indicated. The patient also has been complaining of headaches that have continued since his issues 1 month ago. The consult was requested to evaluate patient’s right eye. Patient was transported over to my office in the Medical Building.
PHYSICAL EXAMINATION: A complete eye exam was conducted. Visual acuity without correction was 20/30 in the right eye and no light perception in the left eye. Intraocular pressure was 15 in both eyes by applanation tonometry. The pupil in the right eye was 4 mm going to 2 mm, briskly. The left eye 5 mm, fixed, no reaction with a 3+ afferent pupillary defect. Slit lamp exam revealed a clear cornea on the right eye. The left eye, the patient has a dense superonasal scar. The anterior chambers were deep and quiet. Lenses: Patient had intraocular lenses in place. The conjunctiva was not injected and the sclera was nonicteric. A dilated fundus exam revealed a cup to disk ratio of 0.3 in both eyes. The optic nerve in the right eye appeared to be normal with no evidence of edema or hemorrhage. The left eye, there was noticeable pallor to the optic nerve.
LABORATORY DATA: The patient’s labs were reviewed and it was significant for an elevated sed rate of 64 and a C-reactive protein of 3.58.
MEDICATIONS: A review of the patient’s medicines revealed that to date he still did not receive any IV steroids. I contacted Dr. XYZ, the patient’s attending, to inquire why steroids were not prescribed and he claimed that he put an order in that was not followed to date. I did not see any order for the steroids in the patient’s chart, but Dr. XYZ claims that he would contact the nurses and start the steroids immediately.
IMPRESSION:
1. History of ischemic optic neuropathy, left eye.
2. Recent amaurosis fugax of the right eye with elevated sed rate and C-reactive protein, concern for temporal arteritis.
PLAN:
1. Patient is to receive IV steroids.
2. Patient is also to have consultation by neurology.
3. Consider temporal artery biopsy if indicated.
I assigned 99232 because of the expanded problem focused history. who’s win?