52 year old female c/o of numbness & tingling in her Right hand and…

Question Answered 52 year old female c/o of numbness & tingling in her Right hand and…   52 year old female c/o of numbness & tingling in her Right hand and leg. some dizziness yesterday when she got up out of bed. Then later she started to have trouble with vision in her R eye making it harder to see everything. Today she continues with vision problems numbness and tingling. unable to remember if she took her medications this morning.PHM: Hypertension, Endometriosis, DM IISurgical History: Total Hysterectomy at age 50 due to EndometriosisMedications: Lisinopril 20 mg BIG and Metformin 500 mg BIDFH: Father living @ age 75 with MI and CABG     Mother Living @ age 73 with A-Fib, Hypertension and DM II   SH: Single. Lives in rural farmhouse. Works teaching 6th grade. Smokes cigs ½ ppd x 20 years. Denies ETOH or other drugs Admits to headache x 3 days, Admits to dizziness and vision loss Admits to “smoker’s cough”Denies chest pain, PND, swelling or sleep difficulties until last pm. Admits to palpitations, intermittentlyGI: Denies appetite changes, nausea, vomiting or diarrhea. Admits to constipation Admits to incontinenceMS: Admits to “dragging R foot” and difficulty with walking,Physical ExamHT: 56 ”   WT: 150 lbs      BP 170/92     HR 110      Resp: 20     O2 Sat 96%    Temp 98.3General: Alert, confused 51 yo female, appearing older than stated age with disheveled clothesHEENT: Normocephalic, Atraumatic, R eye with slowed pupil response L eye pupil reactive, small patches of white circular dots appearing on the retina. Limited vision in R peripheral fields. Ear Canals Clear, TM gray with normal structures. Nares patent w/o flaring, Pharynx clear without CV: Irregular, rapid S1S2. No murmurs, rubs or gallops heard. PMI @ 4th ICS displaced laterallyExt: Warm/dry, +1 pitting edema bilaterally to knees, + 2 radial and pedal pulsesMS: Decreased sensation bilateral lower extremities. Abnormal gait favoring the R leg. Upper/Lower Extremities with FROM. Negative Pronator Drift.LABS: Accuchek: 2571)     Discuss the abnormal History, Physical, Lab Findings.2)     List your differential dx.3)     What is your DO NOT MISS Dx?4)     What additional labs, imaging would you perform? Health Science Science Nursing Share QuestionEmailCopy link Comments (0)

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