Name: Mrs. C

Sex: Female

Address: Long Beach, NY

Date of Birth: 8/15/1979, 41 years old

Date & Time: 5/5/21, 9:30 AM

Location: Northshore University Hospital, Manhasset, NY

Religion: Christian

Marital Status: Married

Race: African American 

Source of Information: Self

Reliability: Reliable

Source of Referral: Opthalmologist

Mode of Transport: Ambulance

Chief Complaint: “My vision is blurry” x 1 week

History of Present Illness:

41 year old African American female with no significant PMH presents to the ED on 5/5/21 referred by ophthalmologist complaining of bilateral blurry vision in eyes x 7 days. Patient stated that a few days ago, she noticed she was seeing blurry, and it has been getting worse and worse over the past few days, which prompted her to see a doctor. She states that the blurred vision is constant and nothing aggravates or alleviates it. She reports the R eye is worse than the L as she is unable to focus in the R eye completely. She denies any pain in her eyes, and denies taking any medication for it. Pt states this has never happened before. Patient denies headache, light sensitivity, difficulty speaking and difficulty moving arms or legs.  Pt does not wear glasses or contacts. In triage, pt’s BP was 196/114. Does not have a hx of high BP or DM. Denies family history of eye problems or strokes.  

She was treated with BP meds and now her BP is controlled with two antihypertensives- Amlodipine and Hydralazine. CT head, CTA H&N, Echo are normal, Hb A1-c  is 5.8. She was seen by Ophthalmology, Cardiology. Renal duplex US is pending. 

Currently, on 5/5/21, patient has no complaints and states that she is able to see better, though her vision is still slightly blurred in the R eye.

Past Medical History:

Present medical illnesses – none

Past Illnesses- none

Childhood illnesses – none

Immunizations – Up to date

Screening Tests- none

Blood Transfusions- none

Past Surgical History:none

Medications- all added upon hospital admission:

1. Amlodipine 10 mg oral tablet, 1 tab PO, once a day, for HTN
2. Hydralazine 50 mg oral tablet, 1 tab PO, 3 times a day, for HTN
3. Atorvastatin 40 mg oral tablet 1 tab PO, once a day (at bedtime), for HLD

Allergies:

No known food, drug, or environmental allergies.

Family History:

Mother – 65, Alive and Well

Father – 71, has HTN and Diabetes

Son- 14, Alive and Well

Daughter- 11, Alive and Well

Daughter-10, Alive and Well

Maternal/paternal grandparents – Deceased at unknown age and unknown reasons

Social History:

Mrs. C is a married female, living at home with her husband and children. She works as an accountant, and has been working from home since the beginning of Covid.

Habits – Patient drinks one cup of coffee a day. Admits to drinking about 1 alcoholic drink a week. Denies smoking, use of e-cigarettes or any illicit drug use. 

Travel- Denies any recent travel.

Safety- Admits to wearing seat belt.

Sleep – Admits to generally sleeping well, for about 8 hours every night. She states that she did not sleep well last night due to the television from her hospital roommate being too loud.

Exercise – States that she does not regularly exercise or engage in physical activity.

Diet- Patients maintains a balanced diet, including fruits and vegetables. She generally has just coffee for breakfast, and eats carbs with vegetable sides for lunch and dinner.

Sexual History: Monogamous, has single male partner. Currently sexually active. Admits to using contraception. Denies history of sexually transmitted infections.

Review of Systems:

General – Denies loss of appetite, recent weight loss or gain, current generalized weakness, fatigue, fever, chills, or night sweats.

Skin, hair, nails –Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus or changes in hair distribution.

Head – Denies dizziness, headaches, vertigo or head trauma, unconsciousness, head fracture or coma.

Eyes –Denies use of glasses, contacts, visual disturbances, fatigue, lacrimation, photophobia, and pruritus. Last visit with ophthalmologist was 3 days ago. .

Ears –Denies tinnitus, ear pain, hearing loss, discharge, or use of hearing aids.

Nose/sinuses – Denies discharge, obstruction or epistaxis.

Mouth/throat –Denies sore throat, sore tongue, bleeding gums, mouth ulcers, voice changes. Last dental exam in February- normal. 

Neck – Denies localized swelling/lumps or stiffness/decreased range of motion

Breast- Denies lumps, nipple discharge, and pain.

Pulmonary system – Denies dyspnea, dyspnea on exertion, shortness of breath, cough, wheezing, orthopnea, paroxysmal nocturnal dyspnea, cyanosis or hemoptysis.

Cardiovascular system –Admits to hypertension and edema/ swelling of the ankles/feet. Denies chest pain, palpitations, irregular heartbeat, syncope or known heart murmur.

Gastrointestinal system –Denies changes in appetite, intolerance to foods, abdominal pain, nausea, vomiting, diarrhea, constipation, dysphagia, pyrosis, flatulence, eructation, jaundice, hemorrhoids, rectal bleeding, or blood in stool. 

Genitourinary system – Deniesurinary frequency, urgency, polyuria, oliguria, nocturia, incontinence, dysuria, hesitancy, dribbling, or flank pain.

Musculoskeletal system – Denies muscle/joint pain, arthritis, deformity or swelling, or redness.

Nervous System– Denies seizures, loss of consciousness, ataxia, loss of strength, change in cognition / mental status / memory, or asymmetric weakness.

Peripheral vascular system –  Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema or color changes.

Hematological system – Denies anemia, easy bruising or bleeding, lymph node enlargement, or history of DVT/PE.

Endocrine system –Denies polyuria, polyphagia, polydipsia, heat or cold intolerance, excessive sweating, hirsutism, or goiter.

Psychiatric –Admits to occasional depression/sadness over the past year as a result of being in the house due to COVID. Denies anxiety, OCD or ever seeing a mental health professional.

 Physical Exam

General: 41 year old female, alert and oriented to person, place and time. Patient is of average build and has good posture, is well dressed, well groomed, and has good hygiene. Patient appears in no apparent distress.

Vital Signs: BP: 158/82, supine                       

R: 18 breaths/min unlabored     

P:98 beats/min, regular       

T: 36.8 Degrees C (oral)                      

O2 Sat: 99% on Room air

Height: 66 inches                Weight: 208 pounds            BMI: 33.6- obese

Skin- Warm and dry, smooth, poor turgor, nonicteric, with fistula on left arm for dialysis placement. No lesions, masses, scars, tattoos, thicknesses or opacities.

Hair- average quantity and distribution. Coarse, no lice or seborrhea noted.

Nails- Normal color size and shape of the nails. No spooning, clubbing, beau’s lines fissures, paronychia noted. Capillary refill <2 seconds throughout hands and toes.

Head-Atraumatic, normocephalic. Nontender to palpation on the frontal, temporal, occipital, and parietal areas. No deformities or specific faces noted.

Eyes-Symmetrical OU. Eyebrows and eyelashes even distribution, eyelids have no discharge or swelling, lacrimal glands have no excessive tearing, dryness, enlargement or erythema, lacrimal sac not inflamed or swollen. No evidence strabismus, exophthalmos or ptosis. Sclera red and injected, conjunctiva and cornea clear.  Visual fields full OU. Visual Acuity 20/40 OD, 20/20 OS, 20/20 OU, PERRLA, EOMs intact with no nystagmus. 

Ears- Symmetrical and normal size. No lesions, masses or trauma on external ears. No discharge/foreign bodies in external auditory canals AU. Tympanic membrane pearly white/intact with cone of light in normal position AU. Auditory acuity intact upon whisper test.

Nose-Symmetrical, no masses lesions or deformities, trauma or discharge. Nares patent bilaterally, nasal mucosa pink & well hydrated. 

Sinuses- Non-tender to palpation and percussion over bilateral frontal and maxillary sinuses. 

Mouth

Lips -Moist; no cyanosis or lesions

Mucosa -Pink, No masses; lesions noted. No leukoplakia.

Palate – Pink, well hydrated. Palate intact with no lesions; masses; scars. 

Teeth -all teeth intact, good dentition, no cavities noted.

Gingivae – Pink; moist. No hyperplasia; masses; lesions; erythema or discharge.

Tongue –Pink; moist, well papillated; no masses, lesions or deviation noted.

Oropharynx – Well hydrated; no injection; exudate; masses; lesions; foreign bodies. Tonsils present with no injection or exudate. Uvula pink, no edema, lesions. 

Neck – Trachea midline. No masses; lesions; scars; pulsations noted. Supple; non-tender to palpation.   

Thyroid- Non-tender; no palpable masses; no thyromegaly; no bruits noted.

Thorax & Lungs 

Chest – Symmetrical, no deformities, no evidence of trauma. Respirations are unlabored, no paradoxical respirations or use of accessory muscles noted. Lat to AP diameter 2:1. Non- tender to palpation. 

Lungs – Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. No adventitious sounds. 

Abdomen-Abdomen flat and symmetric with no striae, scars or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. Abdomen soft and non-tender to palpation across all 4 quadrants, no guarding or rebound noted. No hepatosplenomegaly to palpation, no CVA tenderness appreciated. 

Heart-Normal rate and rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated. Carotid pulses are 2+ bilaterally without bruits.

Mental Status Exam- patient is alert, attentive, and oriented. Speech and language are clear and fluent with good word comprehensio.. Appears to be in good mood, has insight and judgment in his medical problems. Memory and cognitive ability intact, gave accurate information upon assessment of history.

Cranial Nerve Exam – 

CNII-visual fields full by confrontation, red reflex present

CN III, IV, and VI- extraocular movements intact, PERRLA, no ptosis

CN V- face sensation intact bilaterally, corneal reflex intact, jaw muscles strong without atrophy

CN VII- facial expressions intact, clearly enunciates words

CN IX and X- no hoarseness, uvula midline with elevation of soft palate, gag reflex intact, no difficulty swallowing

CN XI- full range of motion at neck with 5/5 strength and strong shoulder shrug

CN XII- tongue midline without fasciculations, good tongue strength

Peripheral Nervous System-

Motor/Cerebellar-Full active/passive ROM of all extremities. Symmetric muscle bulk, slight atrophy, no tics, tremors or fasciculation. Strength 5/5 throughout Romberg negative, no pronator drift noted.

Sensory-Intact to light touch, sharp/dull, and vibratory sense throughout.   Proprioception, point localization, extinction, stereognosis, and graphesthesia intact bilaterally.

Reflexes-2+ throughout.

Peripheral Vascular Exam- Skin normal in color and warm to touch upper and lower extremities bilaterally.  No calf tenderness bilaterally, equal in circumference, no edema. No palpable cords or varicose veins bilaterally. No palpable inguinal or epitrochlear adenopathy. No cyanosis, clubbing / edema noted bilaterally.

Labs:

Hematology:

WBC-7.4

RBC-4.67

Hemoglobin-13.4

Hematocrit-40.2

MCV-86.1

MCH- 28.7

Platelets- 294

Chemistry:

Na- 139

K- 3.5

Cl- 102

CO2-22

Anion gap- 15

BUN-22

Cr-1.00

Glucose.Serum- 93

Calcium- 9.5

Protein- 7.9

Albumin-4.2

Bilirubin-0.4

Alk phos- 95

AST- 13

ALT-11

GFR-81

A1C- 5.9 (prediabetic)

Cholesterol- 223- high

Triglycerides- 72

HDL cholesterol- 61

Non HDL Cholesterol- 163- high

LDL Cholesterol Calculated- 148-high

Imaging:

5/3- CT angio head and neck w/ and w/o w/IV contrast

IMPRESSION:

    1.   Right carotid system:  No hemodynamically significant stenosis.

    2.   Left carotid system:  No hemodynamically significant stenosis.

    3.   Intracranial circulation:  No hemodynamically significant stenosis.

    4.   Brain: Unremarkable.

EKG- 5/4-Ventricular Rate 90 BPM,Atrial Rate 90 BPM,P-R Interval 136 ms,QRS Duration 74 ms, Q-T Interval 388 ms, P Axis 55 degrees, R Axis -20 degree,T Axis 34 degrees

 NORMAL SINUS RHYTHM

CANNOT RULE OUT ANTERIOR INFARCT , AGE UNDETERMINED

NO PREVIOUS ECGS AVAILABLE

TTE-. Normal mitral valve. Minimal mitral regurgitation.

2. Normal trileaflet aortic valve. No aortic valve

regurgitation seen.

3. Hyperdynamic left ventricular systolic function.

4. Normal diastolic function

5. Normal right ventricular size and function.

*** No previous Echo exam.

Assessment

Mrs. C is a 41 year old African American female with no significant PMH presenting to the ED referred by ophthalmologist complaining of bilateral blurry vision in eyes x 7 days. Upon triage, her BP was 196/114. She was given 2 antihypertensive medications and now her BP is better controlled. She was seen by ophthalmology and cardiology. She denies current symptoms of blurred vision. She is currently awaiting further testing to investigate the cause of her hypertension.

Differential Diagnoses:

1. Hypertensive Retinopathy- patient c/o blurred vision and patient had very high BP upon triage. Symptoms improved with lowering of BP
2. Central Retinal Artery Occlusion- patient had painless, semi-gradual loss of vision that was worse in one eye, risk is increased with high blood pressure. Can also be caused by cholesterol emboli and she has hyperlipidemia. Diagnostic angiography was not performed.
3. Retinal Hemmorhage- patient has painless vision loss and blurred vision, which is now improving, and has htn which is a risk factor. However, denies red tinted vision, floaters, or brief flashes of light in peripheral vision.
4. Diabetic Retinopathy – patient has gradually blurring vision and vision loss. However, patient is only pre-diabetic- does not have diabetes, and this would usually come on a few years after developing diabetes.
5. Normal Vision Loss-patient is c/o progressive painless blurriness and loss of vision. However, it improved with BP medication, and normal vision loss is usually a more gradual, but steady decline.
6. Cataracts- patient has painless blurred vision. However it is not particularly worse at night, and is improving without any invasive intervention.

Problem List/Plan – 

1. Blurred Vision- suspecting hypertensive retinopathy, blurriness improved s/p anti-htn medications, currently still 20/40 OD. Follow up with opthalmologist and PCP next week. 
2. Hypertension/ Hypertensive Emergency- improved s/p hydralazine and amlodipine, but still slightly high. Encourage lifestyle changes such as healthy diet, exercise, and limiting caffeine and alcohol intake. Follow up with PCP in one week to further evaluate and assess potential need to adjust medications/ dosing.
3. Obesity- patient has BMI 33.6. Educate about dangers associated with obesity, diet and lifestyle changes. 
4. High Cholesterol/ LDL Cholesterol-recently added atorvastatin. Follow up labs to ensure levels are decreasing. Educate patient about dangers of hyperlipidemia and importance of healthy eating habits.
5. Pre-diabetes-A1C 5.9- educate patient about limiting sugar intake and healthy diet. Repeat A1C test in one year.