Blurred Vision

Chief Complaint

“My vision seems to be getting worse but lately this left eye of mine is just getting even more blurry.”

Patient Profile

Name: Mary Williams

Age: 54

Gender: female

History of Present Illness

M.W. is a 54-year-old woman with a history of uncontrolled type 2 diabetes mellitus* for 14 years, who presented with blurry vision for the past 3-4 months.* The blurriness was described as constant.* The patient reported that the vision changes have been gradually worsening. She also reported that most colors are dull or almost gray.*

There was no associated eye pain, redness, discharge, or photophobia. The patient denied seeing floaters, flashes of light, or curtain-like vision loss.* No recent trauma or new medications reported.*

Mrs. Williams mentioned that her blood glucose levels had been poorly controlled recently, with frequent readings above 235.* Reported polyuria over the last two weeks.* Denies headache, dizziness, weakness, or other neurological symptoms. No recent illnesses reported.

Past Medical History

Diabetes mellitus type 2, hyperlipidemia, obesity, conversion disorder

Medications

• Losartan: 50 mg by mouth daily
• Hydrochlorothiazide: 25 mg by mouth daily
• Atorvastatin: 40 mg by mouth daily
• Vitamin D: 1,000 IU by mouth daily
• Loratadine: 10 mg by mouth daily
• Amlodipine: 5 mg by mouth daily
• Metformin ER: 1,000 mg by mouth twice daily
• Lantus: 10 units SQ nightly

Social History

• Medical secretary
• Lives alone
• Alcohol use: rarely (1-2x per year)
• Tobacco smoke: none
• Illicit drug use: none

Family History

• Mother: Deceased at age 32 from motor vehicle accident
• Father: Hypertension, hyperlipidemia, tobacco smoke

Review of Systems

• Constitutional: Denies chills, fever, fatigue, weight gain and/or weight loss.
• HEENT: Denies postnasal drip, sore throat, hearing impairment. Endorses bilateral blurred vision (left greater than right).* Unable to clearly see blue colored items; believes they are gray.*
• Respiratory: Denies shortness of breath, cough, wheezing.
• Cardiovascular: Denies chest pain and pedal edema.
• Gastrointestinal: Denies abdominal pain, tenderness. Denies constipation, nausea, diarrhea, melena, hematochezia.
• Dermatological: Denies breaks in the skin, lesions and rashes.
• Neurological: Denies headaches, dizziness, tremors. Endorses lower extremity paresthesia.*
• Hematologic: Denies easy bruising.

Physical Assessment

Vitals

• Blood pressure: 146/92 mm Hg
• Heart rate: 76 bpm
• Respiratory rare: 18 bpm
• Temperature: 97.6℉
• Oxygen saturation: 99% on room air
• Height: 67 in

Assessment

• General appearance: Alert, oriented, morbidly obese.
• HEENT: Moist mucous membranes, Snellen visual acuity: OS 20/40, OD 20/30. Color vision test abnormal; unable to identify blue colored numbers.*
• Cardiovascular: Normal rhythm without murmurs; normal s1 and s2; mild trace pedal edema in bilateral lower extremities.
• Respirations: Clear to auscultation bilaterally.
• Abdomen: Active bowel sounds x4, nontender to palpation, no guarding.
• Derm: Without abrasion or ulceration, color is appropriate for ethnicity, acanthosis nigricans.*
• Neurological: No focal deficits, no signs of confusion or cognitive impairment, monofilament not performed.
• Extremities: No asterixis with extension of hands. Monofilament test positive for diabetic neuropathy in bilateral lower extremities.*

Diagnostic Testing

Completed 4.5 months before visit

Assessment

Most likely diagnosis: Mild to moderate vision loss secondary to diabetic retinopathy

Additional differential diagnoses: hypertensive retinopathy, cataracts

Treatment Plan

1. Urgent referral to ophthalmology group
2. Repeat metabolic panel and diabetes screening (Comprehensive Metabolic Panel, Lipid Panel, Hemoglobin A1C, Urine Microalbumin)
3. Lifestyle modifications: diabetic/low carb diet, low salt diet
4. When to seek help: sudden loss of vision, loss of visual field, chest pain, shortness of breath, fevers, chills, face or arm numbness