Monday, June 6, 2011

Intern Report Case Presentation 4.1


Case Presentation by Dr. Sarah Hyatt




Case
Chief complaint: “I can’t see”
28 year old female comes to the ER for loss of vision for 2 days, patient states that this happened suddenly after she was vomiting.  Patient is 6.5 months pregnant and has hyperemesis gravidarum that has persisted through her entire pregnancy. She denies any eye pain and the vision has not improved.  She says she is unable to see anything from the left eye. Previous to this she has not had any trouble with her vision, other than wearing reading glasses.  She decided to come to the ER because her vision still has not improved. She has history of hypertension but no longer requires medication. Denies any headache, fever, chills, chest pain, palpitations, shortness of breath, abdominal pain diarrhea, constipation, dysuria, vaginal bleeding or discharge, no recent travel, no sick contacts.

ROS: negative except as noted per HPI.
PMH:  Hx of Hypertension no longer on medication
Surg hx: none
Gyn: G1P0, good prenatal care
Meds:  Prenatal vitamins 
Allergies: Vicodin causes “throat to close”
FH: Hypertension and diabetes run in the family
SH: No tobacco/alcohol/drugs

PE:  vitals: T 98.7, HR 76, BP 110/56, RR 18, pulse ox 100% RA,  weight 231, 5’5’’
General:  28 year old, African American female, sitting converses without difficulty
Skin: No rashes or scars
Head: normocephalic, atraumatic
Eyes:  EOMI, PERRLA constricting from 6 to 3 mm bilaterally with light, no afferent pupillary defects, Pt has 20/20 VA in right eye,  left eye able to finger count correctly at 5 ft. In her left eye her vision is more clear in her peripheral fields than centrally, intraocular pressure R eye 12, L eye 13, peripheral fields are intact by confrontation, on fundoscopy there were no distinct optic discs visualized, no pallor, no icterus
Nose: symmetric, no discharge
Mouth, throat: No erythema or exudates
Neck: No tracheal deviation or masses
Heart: RRR, S1, S2 heard no murmurs rubs or gallops
Respiratory: CTA BIL
Abd: gravid uterus above the umbilicus consistent with 26 week gestation, soft NT ND,
CNS: Alert and oriented x 3, cranial nerves:  II, III, IV, and VI  see eye exam above, good eyelid opening bilaterally; V, corneal reflex intact bilaterally facial sensation intact bilaterally in V1,V2, V3, good jaw opening, and bite strength; VII, eyebrow raise, eyelid close, smile, frown, pucker, and taste all intact and equal bilaterally; VIII equal auditory acuity to finger rub bilaterally; IX good swallow reflex, positive gag reflex; XI good lateral head rotation, neck flexion, shoulder shrug bilaterally; XII midline tongue protrusion and equal strength on lateral deviation bilaterally. Equal strength in the upper and lower extremities bilaterally, speech and gait are normal.
Extremities: no peripheral edema, all peripheral pulses are felt, good range of motion, no weakness
Labs:       136    101    5      Glucose 82, Ca 9.1, ALT 13, AST 21, total protein 7.1, albumin 3.4, uric acid 4.2                   4.0     23       0.7   Alkaline phosphatase 166, negative UDS and UA 
      10.2
13.5        451  MCV 81.7       Fetal heart tone 150’s
          32.6



Questions

1.     After you dilate the pupil this is your fundoscopic exam. Your diagnosis is?
A. acute glaucoma
B. vitreous hemorrhage
C. central retinal vascular occlusion
D. valsava retinopathy
E. central retinal vein occlusion

2. The patient should be advised which of the following?
A. use aspirin
B. sleep in a sitting position
C. decrease fiber intake
D. resume normal physical activity
E . all of the above

3.Which of the following are risk factors for the above diagnosis?
A.diabetes
B.hypertension
C.anemia
D. idiopathic thrombocytopenic purpura
E. all of the above

Please submit your answers as a comment. Your submission will not immediately post.  Answers with a case discussion will post on Friday.  If you have any difficulty, please contact the site administrator at arosh@med.wayne.edu. Thank you for participating in Receiving’s: Intern Report


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