Case Study for a Patient: Assessment and Treatment Plan

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Subjective

  • Decrease of vision in the left eye; pain when moving it; inability to determine colors.
  • Decrease started this morning and has worsened over the past few hours; the condition improves in a cooler environment.

Past History

  • No injuries in the past; no exposure to chemicals.
  • The patient is a 32-year-old math teacher.
  • The patient is alert, appears anxious.
  • No family history is available.
  • No information on medications.
  • No allergies are identified.
  • No information on immunization.

Health promotion/health maintenance

  • No specific information on health promotion.

Screening/Exams

  • Negative Romberg; normal finger to nose.

Review of Systems

  • No fever, chills, night sweats, weight loss, fatigue, headache.
  • Visual acuity 20/200 in the left eye and 20/30 in the right eye. Sclera white, conjunctiva clear. Unable to assess visual fields on the left side; visual fields on the right eye are intact. Pupil response to light is diminished in the left eye and brisk in the right eye. The optic disc is swollen. Full range of motions; no swelling or deformity.
  • No changes in hearing, sore throat, nasal or sinus congestion, neck pain or stiffness, chest pain, or palpitations.
  • No swelling in the legs.
  • No shortness of breath or cough.
  • No abdominal pain, diarrhea, constipation, polydipsia, and polyphagia.
  • No dysuria, vaginal discharge, polyuria.

Review of Systems

  • Muscles with normal bulk and tone.
  • No integumentary changes.
  • Reflexes: 2+ and symmetric in biceps, triceps, brachioradialis, patellar, and Achilles tendons; no Babinski.
  • Oriented x3.
  • No endocrine changes.
  • Intact to temperature, vibration, and two-point discrimination in upper and lower extremities.
  • No allergic reactions were identified.

Vital Signs

  • BP 135/85 mm Hg; HR 64bpm and regular, RR 16 per minute, T: 98.5F.

Physical Exam

  • The patient appeared well with normal vital signs.

Assessment

Visual or laboratory examinations are not required to make a diagnosis, but they can be conducted to gather additional information. The medical diagnosis is optic neuritis or inflammation of the optic nerves. The disease is characterized by loss of vision, which progresses over several hours or days, the patient may experience pain in the eye socket and on movement (Micieli & Margolin, 2015). The pain is associated with irritation of the inflamed optic nerve. Relative afferent pupillary defect and decreased central visual acuity are the main signs of the disease on examination (Micieli & Margolin, 2015). The prognosis and treatment of the disease depends on the duration and nature of vision loss, the etiology of the disease, as well as injuries and treatment success.

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Differential diagnosis is multiple sclerosis (MS), as it is often associated with optic neuritis. The disease is characterized by “high-contrast visual acuity loss is moderate, with the majority of patients having acuity better than 20/200” (Bennett, 2020, p. 3-4). Despite this, optic neuritis is more common in NMOSD and MOG-IgG disease than in MS. For the diagnosis specification, magnetic resonance imaging is recommended for the patient.

Neuromyelitis optica spectrum disorder is another possible diagnosis, which is “antibody-mediated disease of the central nervous system” (Huda et al., 2019).

Plan/Treatment

In most cases, optic neuritis improves on its own, but steroid use is recommended to reduce inflammation. Steroid therapy is administered intravenously and accelerates the recovery of vision but does not affect its function. The recommended medications are “IV methylprednisolone (1000 mg/d for 3 days), followed by oral prednisone (1 mg/kg/d for 11 days)” (Bennett, 2020, p. 5). In case of worsening of the situation and persistent loss of vision, it is worth using plasma therapy. However, there is currently no evidence of the effectiveness of this method.

References

Bennett, J. L. (2019). Optic neuritis. Continuum, 25(5), 1236-1264. Web.

Huda, S., Whittam, D., Bhojak, M., Chamberlain, J., Noonan, C., Jacob, A., & Kneen, R. (2019). Neuromyelitis optica spectrum disorders. Clinical Medicine, 19(2), 169-176. Web.

Micieli, J. A., & Margolin, E. (2015). A 30-year-old woman with vision loss and painful eye movements. Canadian Medical Association Journal, 187(9), 673–675. Web.

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Reference

NursingBird. (2022, August 12). Case Study for a Patient: Assessment and Treatment Plan. Retrieved from https://nursingbird.com/case-study-for-a-patient-assessment-and-treatment-plan/

Reference

NursingBird. (2022, August 12). Case Study for a Patient: Assessment and Treatment Plan. https://nursingbird.com/case-study-for-a-patient-assessment-and-treatment-plan/

Work Cited

"Case Study for a Patient: Assessment and Treatment Plan." NursingBird, 12 Aug. 2022, nursingbird.com/case-study-for-a-patient-assessment-and-treatment-plan/.

References

NursingBird. (2022) 'Case Study for a Patient: Assessment and Treatment Plan'. 12 August.

References

NursingBird. 2022. "Case Study for a Patient: Assessment and Treatment Plan." August 12, 2022. https://nursingbird.com/case-study-for-a-patient-assessment-and-treatment-plan/.

1. NursingBird. "Case Study for a Patient: Assessment and Treatment Plan." August 12, 2022. https://nursingbird.com/case-study-for-a-patient-assessment-and-treatment-plan/.


Bibliography


NursingBird. "Case Study for a Patient: Assessment and Treatment Plan." August 12, 2022. https://nursingbird.com/case-study-for-a-patient-assessment-and-treatment-plan/.