1. John
R.
Martinelli,
MSIII
SGUSOM
Case
#1:
History
12/5/13
Identifying
Information
Ms.
K.P.
is
a
pleasant
61-­‐year-­‐old
Caucasian
lady
who
presented
to
the
St.
Barnabas
IMFP
service
on
the
evening
of
December
5,
2013.
Chief
Complaint
No
specific
complaints
or
new
symptoms
on
this
previously
scheduled
6-­‐month
follow-­‐up
visit.
History
of
Present
Illness
Ms.
K.P.’s
history
includes
Hashimoto’s
thyroiditis,
a
thromboembolic
event/retinal
arteriolar
embolic
Hollenhorst
plaque,
and
depression.
Ms.
K.P.’s
thyroiditis
was
first
diagnosed
in
early
2010
after
she
presented
to
her
former
primary
care
physician
with
characteristic
signs
and
symptoms
of
a
hyperthyroid
state
that
included
weight
loss,
tremors,
palpitations,
as
well
as
agitation.
Labs
and
thyroid
function
was
assessed
which
suggested
acute
inflammatory
thyroiditis.
Subsequent
referral
to
endocrinology
and
biopsy
led
to
the
confirmation
of
Hashimoto’s
thyroiditis.
In
the
months
after
this
initial
diagnosis,
her
thyroid
function
returned
to
normal
and
current
laboratory
results
support
a
persistent
euthyroid
state.
There
is
no
clinical
(weight
gain,
cold
intolerance,
goiter,
myxedema,
etc.)
or
laboratory
evidence
(TSH
0.41)
suggesting
the
development
of
associated
hypothyroidism
at
this
time.
In
August
of
2010,
Ms.
K.P.
awakened
with
sudden
monocular
inferior
altitudinal
visual
field
loss
of
the
right
eye.
Ophthalmoscopy
by
her
primary
eye
doctor
revealed
a
retinal
arteriolar
embolic
Hollenhorst
plaque
occluding
the
superior-­‐
temporal
vascular
arcade
consistent
with
her
visual
field
loss.
She
was
immediately
referred
to
cardiology
for
investigations
in
an
attempt
to
determine
the
embolic
source.
EKG,
Echo,
as
well
as
carotid
doppler
studies
proved
to
be
unremarkable.
There
was
no
evidence
of
cardiac
arrhythmia,
atrial
fibrillation/flutter
or
valvular
disease
–
all
findings
increasing
the
chance
of
an
embolic
event.
Likewise,
carotid
doppler
flow
studies
revealed
minimal
stenosis,
making
a
carotid
source
unlikely.
Concurrently,
a
lipid
panel
showed
a
relatively
normal
profile
(Tchol
185,
HDL
78,
LDL
92,
TG
73).
Despite
these
findings,
at
that
time
Ms.
K.P.
was
placed
on
lipitor
(atorvastatin)
20mg
PO
QD
and
81mg
aspirin
PO
QD
as
prophylaxis,
which
continues
to
be
her
current
therapy.
She
recently
underwent
repeat
visual
field
testing
showing
nearly
100%
resolution
of
her
previous
field
defect.
Ophthalmoscopy
on
her
visit
today
revealed
a
lodged
chronic
embolic
plaque
at
the
superior
disc
margin
of
the
right
eye,
however,
the
retina
appeared
well
perfused
without
evidence
of
prior
ischemic
retinopathy.

2. Ms.
K.P.
expressed
her
struggle
with
depression
after
several
significant
life-­‐
changing
events
over
the
previous
two
years.
In
2011,
her
husband
passed
away
and
shortly
thereafter
her
mother
also
passed.
Additionally,
she
continued
to
work
during
this
time.
Most
recently,
she
has
retired,
sold
her
home,
and
is
readying
for
a
move
out
of
the
area.
She
previously
requested
to
seek
psychiatric
and
psychological
care
that
has
proved
very
effective
according
to
our
discussion
today.
Currently
she
is
taking
citalopram
10mg
PO
QD
as
maintenance
therapy
along
with
alprazolam
0.25mg
PRN
HS
for
breakthrough
anxiety.
Past
Medical
History
Chronic/Active
1. Hyperlipidemia/Hypercholesterolemia/Cardiac
prophylaxis
per
previous
thromboembolic
event
of
unknown
etiology
(2010).
Lipitor
(Atorvastatin)
20mg
PO
QD
Aspirin
81mg
PO
QD
2. Retinal
arteriolar
embolic
Hollenhorst
plaque,
chronic/persistent
(2010).
3. Depression,
chronic
(2011).
Citalopram
10mg
PO
QD
Alprazolam
0.25mg
PO
HS
PRN
Acute/Resolved
1. Hashimoto’s
Thyroiditis,
resolved
(2010).
2. Visual
field
defect
of
right
eye,
resolved
(2010).
Past
Surgical
History
Ms.
K.P.
had
uneventful
cataract
surgery
with
posterior
chamber
phacoprosthesis
placement
in
2012
and
2013
for
the
right
and
left
eye
respectively.
Benign
breast
cysts
removed
“many
years
ago”.
Medication
Atorvastatin
20mg
PO
QD
Aspirin
81mg
PO
QD
Citalopram
10mg
PO
QD
Alprazolam
0.25mg
PO
HS
PRN

3. Allergies
NKDA/NKA
Social
History
Ms.
K.S.
is
recently
retired
and
currently
in
the
process
of
moving
to
condominium
retirement
community.
She
lives
alone
after
the
recent
death
of
her
husband
in
2011.
She
revealed
that
she
began
smoking
approximately
6
cigarettes
per
day
approximately
18
months
ago.
She
had
quit
smoking
10
years
prior
after
a
20-­‐year
history
of
smoking.
She
drinks
an
occasional
glass
of
wine
once
or
twice
per
month.
She
has
never
used
illicit
drugs
and
denies
any
substance
abuse.
She
claims
to
eat
a
healthy
diet,
gets
adequate
sleep,
and
occasionally
is
able
to
exercise
by
walking
30
minutes/day.
Family
History
Father:
Lymphoma
Mother:
Unremarkable
Review
of
Systems
Constitutional:
No
fever,
No
chills,
No
fatigue.
Eye:
Resolved
previous
visual
field
defect,
right
eye.
Ear/Nose/Mouth/Throat:
No
nasal
congestion,
No
sore
throat.
Respiratory:
No
shortness
of
breath,
No
cough,
No
wheezing.
Cardiovascular:
No
chest
pain,
No
palpitations.
Genitourinary:
No
dysuria.
Hematology/Lymphatics:
No
bleeding
tendency.
Endocrine:
No
excessive
thirst.
Immunologic:
Not
immunocompromised.
Musculoskeletal:
No
joint
pain,
No
muscle
pain.
Integumentary:
No
rash.
Neurologic:
Alert
and
oriented
x
4.
Psychiatric:
Depression,
not
suicidal,
not
delusional,
no
halluc.