Heuristic Errors in Medicine: The Patient with a Red Eye Richard K. Reed, M.D., F.A.C.P.
History CC: Problem with right eye PI: RJ is a 40 yo female with Downs Syndrome with itching of the right eye for 3 days. She had associated pain in the eye. Her caregiver could not restrain her from rubbing the eye. There was no known history of trauma to the eye. She had no recent URI symptoms.
PMH Downs Syndrome – functions as 3 yo Leukemia as a child Stroke as result of complication of chemotherapy for leukemia Obesity Hypertension Hyperlipidemia Primary hypothyroidism Sleep apnea
Social History Medications: - HCTZ 25 mg. daily - Lisinopril 10 mg. daily - Levothyroxime 100 mcg. daily - Lovastatin 40 mg. daily - Citalopram 20 mg. daily - D3 2000 units daily - B12 1000 mcg daily NKA No alcohol, tobacco, or other drug abuse Needs help with most ADLs
Family History Father – died recently of complications of diabetes, renovascular hypertension, chronic renal disease, ischemic heart disease Mother – died in 1980s of metastatic breast cancer Aunt – died recently of complications of diabetes and heart failure
ROS No recent URI symptoms No headache No fever No known head or eye trauma No known abuse issues
Physical Examination BP 130/80 Pulse 64 RR 16 Temp 97.4 Weight 170# Height 4’7” BMI 39.5 kg/m2 No known narcotic or elicit drug use No tobacco use
Physical Examination cont. Gen – obese, Downs phenotype, constantly rubbing her right eye HEENT -visual acuity – not able to access -examiner difficulty on observing right eye -right eye red with conjunctival suffusion -brief look at cornea- no problem -fundus exam impossible -fluorescein staining – NA -slit lamp exam - NA
Physical Examination cont. Neck – short Chest – clear Heart – RRR with no murmur Abdomen – obese, no organomegaly Extremities – mild pretibial edema Neuro – wheelchair bound; residual neurologic sequelae of mild left hemiparesis
Assessment Right red eye – conjunctivitis, iritis or corneal abrasion Downs Syndrome Obesity
Plan Unsure of correct diagnosis, I referred her to an ophthalmologist.
Clinical Course Ophthalmologist 1. He did eye exam the following morning and prescribed eye drops. 2. She returned to see him in 4 days. a. Ophthalmologist was apparently unable to adequate exam. b. With suspicion for underlying pathology, he took her to surgery for exam under anesthesia and found a corneal perforation. c. Evisceration (not enucleation) procedure was performed. d. Prosthetic ball was placed into scleral husk
Later Clinical Course Patient would not leave eye guard in place. The ophthalmologist subsequently removed the ball from the scleral husk. The scleral husk was left in place and will atrophy.
Question Any ideas as to what was the underlying problem with this patient’s eye?
Words of Wisdom There is nothing more humbling than the practice of medicine. Continuing Medical Education
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