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CPC Case for October, 2004

Discussant: Dr. Dorothy Sherwood, MD
Presenter: Dr. Katy Moran, MD

CC

“I can’t see.”

HPI

76 yo WF who presented to the clinic for evaluation of gradual visual loss in both eyes over one month. Specifically, she described a gradual onset of grayness, flashes/floaters of “white light and dark spots.” She denied diplopia, headache, or other associated symptoms
PMH
  1. HTN
  2. Scoliosis
  3. Osteoarthritis-lumbar spine
PSH
  1. Right leg vein stripping-for cosmesis
  2. L5 diskectomy-two months ago
  3. Partial thyroidectomy
  4. Total abdominal hysterectomy
MEDICATIONS
  1. Atenolol 50 mg po qd
  2. Triamterene/HCTZ 37.5/25 one tab po qd
  3. Mobic 15 mg po qd
  4. Protonix 40 mg po qd
  5. ASA 81 mg po qd
  6. Premarin 0.625 mg po qd
  7. Folic acid 1 mg po qd
FH Non-contributory

SH

Widowed, lives alone in her home. She has two grown children in the Dallas area. Tobacco: 25 pack years, currently smoking 1⁄2-1 ppd
EtOH: 3-4 alcoholic mixed drinks per day
No illicit drugs
ALLERGIES Codeine (nausea), PCN (rash)
ROS No fever, weight changes, myalgias, arthralgias, congestion, cough, jaw pain.
PHYSICAL EXAM: Vitals:
Afebrile, BP139/73, P64
Gen: No acute distress, alert and oriented x3
HEENT: Right eye with evident cataract, right pupil less reactive than left. Bilateral visual field deficits with some preservation of sight in the central field of vision. Funduscopic exam not performed. Decreased visual acuity: OD 20/200, OS 20/70. Oropharnyx clear.
Lungs: Clear to auscultation bilaterally
Heart: Regular rate and rhythm. No murmurs, rubs, gallops.
Abd: Soft, nontender, nondistended, normal-active bowel sounds.
Ext: Warm, strength and range of motion normal in bilateral upper and lower ext. Hands with CMC deformity c/w OA bilaterally.
Neurological: Alert and oriented x3. Motor strength normal, and sensation intact to touch. Reflexes 2+ throughout, and negative Babinski reflex. Gait not tested due to vision.

LABS:

Na
 
K
  
Cl
  
HCO3
  
Glucose
  
BUN
 "Chem 14 Normal"
Ca
 
Mg
  
Phos
          
Creatinine
Alk Phos
  
AST
 
ALT
 
TP
 
Alb
  
Total Bili
Lipase
  
Lactic Acid
                
                     
Trop I
  
CK
  
CKMB
            
WBC
 7.9
Hgb
 14.4
Hct
 42
Plts
 235
Differential
 nl
MCV
ABG:
ESR
 20
:
Imaging and Other Studies
Carotid doppler ultrasound
 Right 50-65% stenosis, left <40% stenosis.
MRI of brain
 no evidence of CVA
A diagnostic procedure was done and a diagnosis was made.