Subjective Data
Jessica reports to the emergency department chiefly complaining of a sudden left eye visual declination. She also reports difficulties in differentiating colors.
The 32-year-old math teacher stated that the problem started in the morning after she got from the bed. The situation has been deteriorating during the last hours. She reports that nothing relieves or aggravates her condition. Furthermore, she has no claims linking her to trauma, injury, or contact with chemicals. There are no tears or redness in the left eye. However, she feels pain in the left eye movement, which is relieved when she relaxes. Additionally, she has a history of blurred vision, which occurred one month ago. She links the blurring in her vision with overheating because it got relieved by moving into an air-conditioned environment for cooling.
Past History
- The patient reports no history of hospitalization or surgery. She has never been diagnosed with chronic illnesses.
- Jessica is a math teacher. Also, she does not report any drug and substance abuse or alcohol consumption.
- She reports no history of psychiatric illnesses.
- She is not under any medical treatment at the moment.
- The patient reports no known allergies to food or drugs.
Health promotion/Health Maintenance
Jessica aims at regaining comfort and her vision through her medical seeking behavior. She anxiously visited the emergency department for evaluation because the problem was worsening with time. Healthcare providers have a role to play in promoting patients’ health (Kozier et al., 2018). The health promotion should aim at restoring and maintaining Jessica’s health.
Screening/Exams
- The patient screened using the visual acuity test to determine her vision at different distances.
- A slit-lamp examination can be used to examine some parts of the eye to determine any abnormalities.
- Fundoscopy is critical to exam to inspect the retina.
- Blood tests to check for signs of infection.
- Magnetic Resonance Imaging can be used to observe the retinal nerve.
- Optical coherence tomography can be used to determine the thickness of the retinal nerve.
Review of Systems
- Generally, the patient is healthy with no signs of chills, decreased weight, and sweating.
- On review of eyes, the patient has decreased vision on the left eye.
- On review of the ears, noses, mouth, and throat, Jessica reports no signs of hearing difficulties, congested nose or sinus, painful neck, headache, or soreness.
- A review of the cardiovascular system does not indicate any signs of chest pain or palpitations.
- There are no signs of chest pains, coughing, or dyspnea on review of the respiratory system.
- A review of the gastrointestinal system indicates no signs of abdominal pain, diarrhea, or constipation.
- A review of the genitourinary system indicated no signs of vaginal discharge or dysuria.
- The musculoskeletal system has no signs of injuries. The muscles are well toned and bulked.
- The integumentary system indicates no injuries or sweating.
- The neurological system indicates that the patient is conscious, with no headache or coordination changes.
- On psychiatric review, the patient is anxious and has no signs of polyphagia.
- On review of the endocrine system, the patient has no fever, polyuria, or polydipsia.
- The hematologic/lymphatic system indicated no signs of bruising or bleeding.
- On allergic/immunologic review, the patient has no allergies or reactions.
Vital Signs
- BP 135/85 mm Hg, HR 64 bpm, RR 16 bpm, Temperature 98.5F.
Physical Exam
- Generally, the patient is alert but has signs of anxiety.
- Visual acuity of the left eye is 20/200 and 20/20 of the right eye. The sclera and conjunctiva are normal. The left eye has reduced pupil response and difficulties in evaluating visual fields. Additionally, the optic disk of the left eye is distended.
- A musculoskeletal exam indicates no deformities or swellings. The muscles have standard bulk and the right tone, with the joints moving in a full range of motion.
- Neurological exam indicates that all cranial nerves are intact, reflexes are normal and symmetrical, and respond to temperature and vibrations.
- On mental exam, the patient is oriented x3
Assessment
- The patient’s diagnosis is optic neuritis due to presence of afferent pupillary defect, decreased left eye acuity, and pain on movement of the left eye.
- Differential diagnoses include Ischemic Optic Neuropathy, which is not accompanied by pain.
- Another differential diagnosis is Leber’s Hereditary Optic Neuropathy, which also has painless vision loss (Bennett, 2019). The condition is inherited from the maternal mitochondrial.
Plan/Treatment
- The patient is put on steroid medication to relieve the inflammation.
- Analgesics are also necessary to reduce the pain associated with eye movements (Chen et al., 2020).
- Bed is also vital to reduce the risks of injuries.
References
Bennett, J. L. (2019). Optic neuritis. Continuum (Minneapolis, Minn.), 25(5), 1236. Web.
Chen, J. J., Pittock, S. J., Flanagan, E. P., Lennon, V. A., & Bhatti, M. T. (2020). Optic neuritis in the era of biomarkers. Survey of ophthalmology, 65(1), 12-17. Web.
Kozier, B., Erb, G., Snyder, S. J., Frandsen, G., & Buck, M. (2018). Fundamentals of Canadian nursing. Concepts, Process, and Practice-Pearson.