Exam:

Vitals: T 99.6, HR 118, BP 148/96, RR 26

General: Patient is distressed, in pain

Ophthalmic Exam:
VA: 20/20 OD , 20/ 200 OS
Ta: 13,16
Pupils: circular, reactive, no APD
CVF: no defects, unable to perform
External: WNL, erythematous and excoriated skin surrounding L eye

SLE:

DFE: OD – Arteries, Veins, Macula, and Periphery WNL. OS – Difficult exam due to photophobia but retina attached.