FACULTY DEVELOPMENT
IN PRIMARY CARE
With Support Provided by:
Health Resources and Services Administration
Grant # D55HP23200
Chief Complaint &
History of Present Illness
 Chief complaint: “I have a change in vision”
 HPI: A 76 year old man presents with progressively worsening vision.
The patient first noticed his vision getting worse about a year ago, so he
went to the optometrist and got new glasses. At the time of his visit he was
told he might be developing cataracts in both eyes. He now notes difficulty
with reading and driving. He states that the vision loss is worse at night, so
now he is afraid to drive at night because of the glare that he sees reflecting
off of the other cars’ lights. In describing the vision change he states that he
is seeing halos around lights when he looks directly into them.
History of Present Illness Cont.
He notes that the vision in both of his eyes has greatly decreased
and that he sometimes sees double. He has not been able to
differentiate between colors recently and he feels that most colors
look “faded” to him.
He is an avid reader and his vision change is greatly affecting his
daily life. He is worried that he will become blind.
Past Medical & Surgical History

PMH: Asthma, High Cholesterol, Hypertension

PSH: Angioplasty with one stent placement two years ago.
Laparoscopic Cholecystectomy 10 years ago
Medications &
Asthma Severity
 Prescribed Medications:
 Albuterol inhaler 1 puff every 6 hours when needed. He uses his
albuterol inhaler three to four times a week. He wakes up at night
once a month with wheezing. He has never been intubated for his
asthma, but has been hospitalized three times in the past 10 years
due to asthma exacerbations. He has been on multiple courses of
steroids throughout his life for Asthma.
 Advair diskus (fluticasone/salmeterol) inhaler 1 puff twice a day
Medications and Allergies
Medications Continued:
 Pravastatin 80 mg po q hs
 Hydrochlorothiazide 50 mg po q day
 Omega 3 fatty acids 1000 mg po q day
 Allergy- Aspirin- had hives
Social History
 Patient worked as an executive in a pharmaceutical company. He retired about
eight years ago and still does consulting work on the side. He traveled a lot for
work and uses the computer a couple of hours per day. He lives with his wife in
his multi level home. He has an active social life and a big family and support
system.
 He is currently married and has three children from his wife and one son from a
previous relationship.
 Drinks one cup of coffee a day, no other caffeine use.
 Drinks alcohol socially (about one glass of wine a month).
 He eats healthy and works out once a week by swimming laps at the local YMCA.
Family History
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Mother deceased at 50 from Endometrial Cancer
Father deceased at 90 from natural causes.
4 healthy children
Health Maintenance
Immunizations:
• Influenza- this year
• Pneumococcal- five years ago
• Tdap 2 years ago, when
grandson was born
• Zostavax- never had
• PPD- never had
Health Maintenance
• Colonoscopy about 5 years ago
• Prostate exam – by urologist this
year
• CXR- 1 year ago
• EKG- 1 year ago
• Exercise stress test at
Cardiologist this year. All
normal
Review of Systems
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General: Well groomed, proper hygiene
Constitutional: No fevers, chills, or night sweats
Skin: No lesions, no ulcers, no itching, no edema
HEENT: No headache, ear pain, sinus pain or sore throat
Eyes: + Cloudy Vision
Breasts: No pain, no discharge, no changes noted.
Respiratory: No active Dyspnea
Heart: No palpitations, no dizziness, no chest pain.
Hematological: No fatigue, no signs of easy bruising.
GI: No reflux, no nausea, vomiting or diarrhea noted. No changes in bowel habits.
No hematuria, no incontinence, no impotence
 Neurologic: No tremors, no headaches, paresthesias, dysarthria or gait instability.
 Psych: Denies anxiety or depression
Comprehensive Geriatric
Assessment Tools
The following tools are utilized when performing a comprehensive
geriatric assessment, along with a thorough history & physical exam:
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Fall Risk: Get Up and Go Test
Barthal Index of ADL’s
IADL’s
Mini Mental Status Examination
Clock Drawing Test
Geriatric Depression Scale
These account for the patient’s gait stability, fall risk, their functional capacity and ability to live
independently, their mental status (which can vary with acute illness and can worsen with age
related disease), their higher cognitive function, and any underlying depression that may worsen
co-morbid conditions.
Gait Stability Assessment
Get up and Go Test:
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■
Scoring:
 1 = Normal
 2 = Very slightly abnormal
 3 = Mildly abnormal
 4 = Moderately abnormal
 5 = Severely abnormal
A patient with a score of 3 or more on the Get-up and Go
Test is at risk of falling.
The patient rises out of chair comfortably, walks forward steadily, pivots without difficulty
and shows a steady gait while walking back.
He scores a 1- Normal get up and go test with no gait abnormality noted.
Assessment of mobility, balance, walking ability, & fall risk
The Timed Up and Go Test (TUG)
Instructions for administration
The patient sits in the chair with his/her back against the chair back.
On the command “go”, the patient rises from the chair, walks 3
meters at a comfortable and safe pace, turns, walks back to the
chair and sits down.
Timing begins at the instruction “go” and stops when the patient is
seated.
Scores range from 1 to 5 based on the observer's perception of the
patient’s risk of falling.
The patient should have one practice trial that is not included in the
score
Patient must use the same assistive device each time he/she
is tested to be able to compare scores.
Podsiadlo & Richardson 1991
TUG Normative Data for Community-Dwelling
Older Adults
Age years
Gender
N
Mean Time
(seconds)
SD
95% CI
60-69
Male
15
8
2
7-9
Female
22
8
2
7-9
Male
14
9
3
7-11
Female
22
9
2
8-10
Male
8
10
1
9-11
Female
15
11
3
9-12
70-79
80-89
Steffen et al, 2002
Equipment required: standard armchair (approx. 46cm high) and stopwatch. Time to Administer: >3 min. ICF
Domain: Activity
Cut-Off Scores for TUG indicating
risk of falls by population
Population
Cut-Off score (in seconds)
Author
Community dwelling adults
>13.5*
Shumway-Cook et al, 2000
Older stroke patients
> 14*
Andersson et al, 2006
Older adults already attending a falls clinic
> 15*
Whitney et al, 2005
Frail elderly
> 32.6*
Thomas et al, 2005
LE amputees
> 19*
Dite et al, 2007
Parkinson's Disease
>7.95*
Dibble et al, 2006
Barthal Index of ADLS
Activities of Daily Living
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Bowels
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0 = incontinent (or need to be given enema)
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1 = occasional accident (once/week)
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* 2 = continent
Bladder
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0 = incontinent or catheterized and unable to manage
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1 = occasional accident (max. once per 24hrs)
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* 2 = continent (for over 7 days)
Grooming
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0 = need help with personal care
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* 1 = independent face/hair/teeth/shaving
Toilet use
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0 = dependent
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1 = needs some help, but can do something alone
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* 2 = independent (on and off, dressing, wiping)
Feeding
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0 = unable
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1 = needs assistance
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* 2 = independent
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■
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Transfer
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0 = unable – no sitting balance
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1 = major help (1 or 2 people, physical), can sit
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2 = minor help (verbal or physical)
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*3 = independent
Mobility
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0 = immobile
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1 = wheelchair independent, including corners
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2 = walks with help of one person (verbal or physical)
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*3 = independent (but may use any aid, e.g., stick)
Dressing
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0 = dependent
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1 = needs help, but can do about half unaided
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* 2 = independent (including buttons, zips, laces,
Stairs
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0 = unable
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1 = needs help (verbal, physical, carrying aid)
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*2 = independent up and down
Bathing
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0 = dependent
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* 1 = independent (or in shower)
TOTAL Score: (Circle score and calculate sum at bottom)
Total possible score 0 – 20 with lower scores indicating increased disability.
The patient scored a Total of 20 no Disability, no problems with transfers & the stairs.
Instrumental Activities of Daily
Living (IADL’s)
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Ability to use telephone
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* 1 = Operates phone on own initiative (looks up & dials)
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1 = Dials a few well-known numbers
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1 = Answers telephone but does not dial
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0 = Does not use telephone at all
Laundry
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1 = Does personal laundry completely
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* 1 = Launders small items; rinses stockings etc.
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0 = All laundry must be done by others
Shopping
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*1 = Takes care of all shopping needs independently
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0 = Shops independently for small purchases
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0 = Needs to be accompanied on any shopping trip
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0 = Completely unable to shop
Housekeeping
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* 1 = Maintains house alone or with occasional assistance
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1 = Performs light daily tasks such as dishwashing, bed making
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1 = Performs light daily tasks but cannot maintain acceptable level of
cleanliness
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1 = Needs help with all home maintenance tasks
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0 = Does not participate in any housekeeping tasks.
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Mode of Transportation
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1 = Travels independently on public trans. or drives own car
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* 1 = Arranges own travel via taxi but does not use public trans.
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1 = Travels on public trans. when assisted or accompanied by aid
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0 = Travel limited to taxi or car with assistance of another
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0 = Does not travel at all
Food Preparation
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*1 = Plans, prepares and serves adequate meals independently
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0 = Prepares adequate meals if supplied with ingredients
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0 = Heats and serves prepared meals or prepares meals but does not maintain
adequate diet
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0 = Needs to have meals prepared and served
Responsibility of own medications
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* 1 = Is responsible for taking medication in correct dosage & time
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0 = Takes responsibility if medication is prepared in advance in
separate dosages (pill box)
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0 = Is not capable of dispensing own medication
Ability to handle finances
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* 1 = Manages financial matters independently (budgets, writes checks, pays
rent/bills, goes to bank)
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1 = Manages day-to-day purchases, but needs help with banking and major
purchases.
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0 = Incapable of handling money
Scoring: The patient receives a score of 1 for each item if his/her competence is rated at some minimal level or higher. Total score range is 0 – 8.
A lower score indicates a higher level of dependence. The patient scored an 8, which is of independent function.
Mini Mental Status Exam
Mini Mental Status Exam: Results
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The patient correctly states the year and the season, he is not
confused.
He remembers all dates and objects.
He is able to copy the object shown with the lines crossing over each
other.
The remainder of his MMSE had appropriate responses.
His total score is 30, which reflects the highest score, no deficits
Clock Drawing Test: Higher
Executive Function & Dementia
The patient draws the image shown in Figure A - normal
Geriatric Depression Scale
(15 point)
Scoring: Score 1 point for each one selected.
A score of 0 – 5 is normal. A score greater than 5 suggests depression.
The patient scored a 1. He does not seem to have depression, but is fearful of driving at night.
Physical Examination
Vital Signs:
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BP- 126/88
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Pulse- 72 regular
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RR-16
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Temp.- 98.6
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190 lbs. 5 ft. 10in. BMI=27.26
Vision Testing
•
Snellen Vision test was 20/40 in both eyes,
without his glasses.
•
Visual Fields were decreased.
Image: Snellen Chart
Visual Acuity Testing
•
Contrast sensitivity testing- evaluates the ability to differentiate
between an object and its background.
•
Contrast sensitivity was decreased in this patient.
www.nap.edu Visual Impairments: Pelli-Robson contrast sensitivity chart (Pelli, Robson, & Wilkins, 1988)
Visual Acuity Testing Cont.
■
Glare testing- done with a Brightness Acuity Test (BAT) to simulate
glare from an artificial light source. Patients with cataracts may have
good distance visual acuity in a dimly lit room, but experience a
reduction in acuity from a bright light.
* This patient had a reduction in visual acuity by the bright light*
http://exton-vision-center-optometry.eggzack.com/cataract-testing
Visual Acuity Testing Cont.
Potential Acuity Meter (PAM) test projects an eye chart directly onto the
retina the lens. This is often useful in estimating how much the cataract is
contributing to the patient’s visual loss.
■ Color Vision Testing assesses the optic nerve and macula.
■ Optical coherence tomography (OCT) is probably the most helpful test for
diagnosing macular pathology.
■ Pupil testing must be performed in all patients!
* This patient had a decrease in visual acuity with these tests, but his pupils
responded normally to light.
■
http://exton-vision-center-optometry.eggzack.com/cataract-testing
Physical Examination
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General appearance: NAD, A&Ox3
Eyes: Pupils equally reactive to Light and Accommodation
HEENT: TM intact b/l no erythema, no mastoid, no tragal tenderness. No erythema on tonsils. Negative
sinus tenderness to palpation. No bruits, No cervical lymphadenopathy, neck supple, no thyromegaly
Neuro: Cranial nerves 2-12 grossly intact bilateral, sensation intact b/l face, negative Brudzinski's sign,
negative Kernig's sign, muscle strength intact bilateral upper and lower extremities. All Reflexes
Normal, sensation to bilateral upper and lower extremities intact.
Lungs: CTA B/L
CVS: s1s2, RRR
Abdomen: NT, ND, positive bowel sounds in all 4 quadrants, obese
Back: No CVA tenderness
Extremities: Normal
VISION DECREASED BILATERAL EYES
Laboratory Tests
 WBC: 5.6
 Hb: 14.0, HCT: 38.7 PLT 265
 FLP- Total cholesterol 200, triglycerides 130
HDL 70, LDL 130
 Liver and Kidneys Normal
 Thyroid Function Tests Normal
 Glucose 105 (nonfasting)
 PSA 1.0
 Negative Lymes titer
 RPR negative
 Vitamin B12, Folate and Vitamin D 25-OH normal
Slit Lamp Exam

Image From: http://en.wikipedia.org/wiki/Cataract
Right Eye
Left Eye
Cataracts

This patient was found to have a decrease in bilateral vision
and Cataracts in both Eyes.

This patient has a history of steroid use due to Asthma
which could have contributed to his Cataract development.
Causes of Cataracts:
 Age- As people age the protein in the eye clumps together
forming a Cataract.
 Injury- Traumatic Cataract
 Wilson’s Disease- Genetic disorder where copper accumulates
in organs.
 Down’s Syndrome
 Viruses and Bacteria
Causes of Cataracts:
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Medication – i.e. Steroids, such as Prednisone
Hypothyroidism
Hyperparathyroidism
Familial Genetic Cataracts
Diabetes Mellitus
Nicotine use (Tobacco Smoking)
Causes of Cataracts:
 Sunlight- there is an increase incidence of Cataracts with
exposure to UV Rays
 Statins- According to New Study by the NIH statins can
increase the Incidence of Cataracts.
http://well.blogs.nytimes.com/2013/09/25/statins-tied-to-cataract-risk/?_r=0
Causes of Congenital Cataracts:
Congenital Cataracts due to Viruses, Bacteria or Parasites:
• Herpes Simplex Virus
• Rubella
• Toxoplasmosis
• Syphilis
• Cytomegalovirus
Cataracts
■
A cataract is an opacity in the crystalline lens of the eye. They cause
degradation of vision and distort light passing through the lens.
Cataracts are common in the elderly and 60% of Americans over the
age of 60 have cataracts. Over 1.5 million cataract surgeries are done
in the US annually.
■
The predominant complaint of patients with Cataracts is gradual vision
loss. Patients also complain of blurry vision, glare, problem seeing
when bright lights are present, and double vision.
Treatment of Cataracts
Most treatment of cataracts revolve around the patient’s vision
complaints. If vision loss is severe and affects the patient’s
quality of life, then Cataract Surgical Extraction is recommended.
This is done by an Ophthalmologist.
Most standards of surgery are when Vision by the Snellen chart is
20/40 or worse in the eye with the cataract.
Cataract Surgery



Cataracts are usually removed by the extracapsular technique in
which the cataract is removed and a new lens is put in place.
Laser treatment is sometimes required after the cataract is
removed.
In the US, Cataract surgery has approximately a 95% success rate.
Types of Cataract Surgery
1. Phacoemulsification: Using a microscope the ophthalmologist
makes an incision in the surface of the eye in or near the cornea. An
ultrasound probe is placed in the eye and vibrations are used to
dissolve the clouded lens. The fragmented pieces are then suctioned
out through the same probe. Once the cataract is removed, an
artificial lens is placed in the capsule.
http://www.medicinenet.com/cataract_surgery/page3.htm#types
Types of Cataract Surgery
2. Extracapsular cataract surgery: This procedure is used mainly for
very advanced cataract that cannot be phacoemulsified. A large incision is
made to remove the whole lens and an artificial lens is placed in the
capsule.
http://www.medicinenet.com/cataract_surgery/page3.htm#types
Types of Cataract Surgery Cont.
3. Intracapsular cataract surgery: Ophthalmologist removes the
lens and capsule and the new lens is placed in the iris. This is an
uncommon type of cataract surgery but is used in traumatic cataracts.
http://www.medicinenet.com/cataract_surgery/page3.htm#types
Cataract Surgery Risks
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•
•
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Inflammation after extraction
Infection
Bleeding
Swelling
Retinal detachment
Glaucoma
Secondary cataract
Loss of vision
Cataract Surgery
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Low risk
Procedure is about an hour in length
Usually requires Pre Operative Clearance
Can be done in a same day ambulatory surgery setting or
in a Hospital Operating Room
Anesthesia for Cataract Surgery
• Most cataract surgery is done using a topical anesthetic
(eye drops) and/or under local anesthesia and sedation.
• General Anesthesia is rarely used for Cataract Surgery
and is used for patients with:
Severe Anxiety
Allergy to local anesthesia
Children
Cataract Treatment for this pt

This patient was referred to an Ophthalmologist
who recommended bilateral Cataract extraction
under local sedation using the phacoemulsion
technique.
Follow Up Visit
The patient saw his Ophthalmologist five days
after surgery and was given a slit lamp exam and a
Vision Test, which showed his vision improved after
surgery.
Two month Follow Up
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Patient seeing well, able to read and drive at night.
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He is back to taking his Omega 3 Fatty Acids and his
Asthma is better controlled.
Osteopathic Considerations
In this 76 year old with bilateral cataracts and chronic asthma with
periodic steroid use, there are several ways that osteopathic treatment
can add to his treatment. In a patient with lifelong asthma and
intermittent steroid use, there will be somatic dysfunctions from the
asthma itself and from the chronic use of accessory muscles of
breathing. Osteopathic treatment can reduce these somatic
dysfunctions and reduce the work of breathing and could have a
positive effect on the frequency, duration and severity of his chronic
exacerbations. This could, in turn, reduce frequency and dosage of
corticosteroids in the future.
Osteopathic Considerations Cont.
Additionally, manipulation of the eye via instrumentation and the
procedure itself can cause cranial somatic dysfunctions, increased
inflammation and swelling, which can be aided through
maintaining cranial base mechanics. The vast majority of venous
drainage from the skull is via the jugular vein.
The jugular vein drains through the jugular foramen which is
situated between the petrous portion of the temporal bone and the
occiput.
Checking this important area in this patient can help with drainage
and may reduce swelling and help with pain, both of which can
augment the healing process.
Osteopathic Structural Exam
• Cranial- zygoma depressed and restricted on R, temporal internally
rotated on L
OA ERrSBl,suboccipital tissues boggy with acute tissue texture changes
and tenderness, R occipito-temporal restriction
• C- C2 Rl, chronically tense SCM’s b/l, Scalenes tense L, tender points
throughout
• T-R- compliance of the thoracic cage reduced, stiffness through ribcage
and T-spine, paraspinal muscles tense T3-L5 b/l, 12th rib inferior and
post b/l, iliopsoas hypertonicity b/l.
• Diaphragm- diminished motion inhalation and exhalation
Osteopathic Treatment
This patient would benefit from treatment as quickly as possible, even right after
surgery, but most likely he would be seen several days post op. Because of his age,
familiarity or lack of familiarity with osteopathic treatment and the acute nature of
his situation, only gentle treatments should be used.
• cr- a simple gentle base spread/ V- spread technique could help with temporal
dysfunction and facilitate greater drainage from the face via jugular foramen
“opening”. Gentle myofascial release and OA decompression should be tolerated
and effective.
• Thoracic cage- gentle seated articulatory technique to reduce thoracic and rib somatic
dysfunctions and decreased compliance of thoracic should be effective and tolerated
but if not, supine rib raising would be an additional or substitute treatment.
Treatment Continued
• R- BLT to 12th rib and or counterstrain to psoas tender points could
be used to release iliopsoas and help with over diaphragm motion.
• C- counterstrain and myofascial release techniques also should be
well tolerated and effective, BLT could also be very effective and
safe in this post op patient with acute and chronic somatic
dysfunctions
Internet References
 http://exton-vision-center-optometry.eggzack.com/cataract-testing
 http://en.wikipedia.org/wiki/Cataract
 http://well.blogs.nytimes.com/2013/09/25/statins-tied-to-cataract-risk/?_r=0
 http://www.medicinenet.com/cataract_surgery/page3.htm#types
 http://www.nlm.nih.gov/medlineplus/cataracts.html
References
▪
Current Medical Diagnosis and Treatment, Chapter 7
Disorders of the Eye and Lids on Access Medicine
Accessed on December 8, 2013.
▪
Paine, D. et al Cataracts on Emedicine Health
Assessed December 7, 2013.
References
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Cheak-Zamora, N. C., Wyrwich, K. W., & McBride, T. D. (2009). Reliability and validity of the SF-12v2 in the
Medical Expenditure Panel Survey. Quality of Life Research, 18 (6), 727–735.
Podsiadlo, D. and Richardson, S. (1991). "The timed "Up & Go": a test of basic functional mobility for frail elderly
persons." J Am Geriatr Soc 39(2): 142-148.
Nasreddine, Z. S., Phillips, N. A., et al. (2005). "The Montreal Cognitive Assessment, MoCA: a brief screening tool
for mild cognitive impairment." Journal of the American Geriatrics Society 53(4): 695-699.
Rossetti, H. C., Lacritz, L. H., et al. (2011). "Normative data for the Montreal Cognitive Assessment (MoCA) in a
population-based sample." Neurology 77(13): 1272-1275.
Steffen, T. M., Hacker, T. A., et al. (2002). "Age- and gender-related test performance in community-dwelling
elderly people: Six-Minute Walk Test, Berg Balance Scale, Timed Up & Go Test, and gait speeds." Physical
Therapy 82(2): 128-137.
Ware JE, Kosinski M, Keller SD (1996). A 12-Item Short-Form Health Survey: Construction of scales and
preliminary tests of reliability and validity. Medical Care. 34(3):220-233. (SF-12v1)
Special Thanks to…
Clinical Case by: Dr. Bernadette Riley, DO
Mary Adar, DO, Assistant Professor, Dept. Family Medicine,
NYIT College of Osteopathic Medicine
Joseph Simone, DO
Corri Wolf, PA-C, MS, RD, Assistant Professor, Dept. Physician Assistant Studies,
NYIT School of Health Professions
Rosemary Gallagher, PT, DPT, GCS, Assistant Professor, Dept. Physical Therapy,
NYIT School of Health Professions
B. Suzanne Diggle-Fox, PhD, RN, Assistant Professor, Dept. Nursing,
NYIT School of Health Professions
Grant Director: David P. Yens, PhD, Associate Professor, Family Medicine,
NYIT College of Osteopathic Medicine