Patient History and Examination: Jessica Case

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Patient History

Jessica is a math teacher at a local school who reported to the emergency department earlier today, due to a sudden and unexpected decrease of vision in her left eye. According to the patient, the condition was present in her since the early morning, gradually becoming worse as the time passed. The condition is followed by pain whenever she tries to move her eye. Another symptom of the disease is colorblindness. According to Jessica, she was never exposed to anything that could have triggered the disease.

Jessica considers herself very healthy. She has never been to a hospital for prolonged periods of time. Major diseases of the past include chickenpox at the age of ten and tonsillectomy at age eleven. The patient is a mother of four, all children having been born without complications. No bad habits. Quit smoking 10 years ago. Occasional alcohol use, but not too much. No evidence of any illicit drug use. Jessica may have predispositions towards coronary artery disease and hypertension.

Patient Examination

Systems Review

  • General: The patient is distressed and has no idea what could be the cause of her condition.
  • Head and Neck: The patient shows no signs of injury or limited mobility in the neck or head.
  • Eyes: According to the patient, she suffers from decreased vision in her left eye, followed by pain when trying to move or rotate the eye within the socket. Cannot identify colors. The condition appeared early in the morning and remained unaffected by the customer’s attempts at treatment. The situation escalated in a few hours. The patient suspects it might have to do something with an overheating episode one month ago.
  • Ears, Nose, Throat, and Mouth: No abnormalities were found.
  • Lymphatic System: No abnormalities were found.
  • Chest and Lungs: The patient does not appear to suffer from any chest pains, coughs, or breath restrictions.
  • Heart and Blood Vessels: Everything appears to be in order.
  • Gastrointestinal System: No complications were found.
  • Gastro-Urinary System: No abnormalities were found.

Endocrine System: No swelling, no evidence of polyuria, polydipsia, or polyphagia was found.

  • Musculoskeletal System: The patient reports minor joint and muscle pains, particularly around the hands and wrists. The pain is not associated with age or a lack of early morning exercise.
  • Nervous system: Altered state. The patient is nervous and alert but does not experience any severe orientation problems.

Physical Examination

  • General examination: The patient is an adult white Caucasian woman. She does not show signs of drug or alcohol influence. She appears anxious but is capable of understanding information and responding accordingly.
  • Mental state: The patient is alert and oriented.
  • Skin: Does not show any flakiness, rashes, or any kinds of other abnormalities. Nails are in healthy condition. Skin does not appear cold, excessively moist, or dry.
  • Head: No abnormalities are found.
  • Eyes: Left eye suffers from unidentified condition, visual acuity dropped to 20/200. Right eye remains at 20/30. The optic disc is swollen. The afflicted eye can be characterized by diminished pupil response to light and has a decreased field of vision. The right eye is largely unaffected.
  • Hearing: No abnormalities were detected.
  • Nose: No discharge. Everything appears to be normal.
  • Throat and mouth: No discharge. The mucosa appears to be intact.
  • Neck: The patient reports no pain or discomfort associated with neck movements.
  • Chest and Lungs: Breathing pattern appears normal. No additional mass or any deformities. The chest expands symmetrically on both sides. Respiratory rate is 16 breaths per minute.
  • Heart: No heart abnormalities are present. The beating is strong and healthy. Heartbeat rate is at 64 bps. BP 135/85 mm Hg. No pulse irregularities were detected.
  • Abdomen: Everything appears to be in norm.
  • Musculoskeletal System: Despite slight pains in the wrists and hands, the patient is not limited in range of motion. No swellings or deformities are present.
  • Neurological Test: The patient’s cranial nerves I-XII remain intact. Signs of horizontal nystagmus are present. Normal finger to nose reaction. Negative Romberg reflex. The patient reacts to temperature, vibration, and two-point discrimination tests. Reflexes are normal and symmetric in biceps, triceps, brachioradialis, patellar, and Achilles tendons. The reaction to Babinski test is negative.

Determining a Presumptive Nursing Diagnosis

The classical framework for developing a presumptive nursing diagnosis is the NANDA-I framework, which provides four categories of nursing diagnosis (Gordon, 2014). Depending on the stage, the nurse will be looking for different physical findings. During the clinical judgment phase, the physical findings that the nurse would be looking for findings that reflect the patient’s experience and responses to their health conditions. In the current scenario, these responses are pain when moving the eye, inability to distinguish colors and seeing properly, as well as the pain in wrists and hands.

During the risk diagnosis stage, the nurse will be looking for findings that would help determine potential for future harm and further responses that may develop in a patient as the disease progresses (Gordon, 2014). In this scenario, it is relatively safe to assume that the disease will not affect the majority of other bodily function, though the potential for afflicting both eyes exists.

Health promotion stage assesses the readiness of the patient to improve his or her health (Gordon, 2014). Findings necessary for assessment is the ability of the patient to listen and comprehend the information provided by the nurse, as well as the ability to carry out the prescribed treatments. According to the findings, Jessica is both willing and capable to undergo treatment and follow instructions.

Based on these symptoms and findings, it is possible to produce several presumptive nursing diagnoses (Tuohy, McCarthy, & Hurley, 2013):

  • Pain and discomfort associated with eye movement.
  • Reduced ability to perceive the surroundings without one of the eyes being fully functional.
  • Reduced capabilities of self-care caused by the ocular impairment.
  • Psychological anxiety associated with the disease.

Nursing Plan of Care

  • Assess the degree of influence of the disease on the patient’s routine behaviors and the degree of discomfort that each of the presumptive diagnoses causes (Tuohy, McCarthy, & Hurley, 2013).
  • Provide means of reducing discomfort through medication and counseling.
  • Provide physical and psychological support to the patient, especially in the early stages of the disease (Tuohy et al., 2013).
  • Provide instructional and learning material in order to teach the patient to cope with the disease and encourage autonomy.

Teaching Plan

  • Assess the patient’s capabilities for autonomy (Ackley, Ladwig, &Macik, 2016).
  • Explain the condition to the patient in short and simple terms.
  • Help the patients through the acceptance phase of the disease, should its effects leave any permanent effects on the patient’s capability to see.
  • Teach pain management techniques.
  • Teach how to reduce pain during sleep preparations.
  • Help the patient understand her own capabilities and limitations pertaining to the disease (Ackley et al., 2016).


Ackley, B. J., Ladwig, G. B., & Macik, M. B. F. (2016). Nursing diagnosis handbook: An evidence-based guide to planning care (11th ed.). New York, NY: Elsevier.

Gordon, M. (2014). Manual of nursing diagnosis (13th ed.). New York, NY: Jones & Bartlett Learning.

Tuohy, D., McCarthy, J., Carmel O., & Hurley. (2013). Nursing care of conditions related to the ear, nose, throat and eye. In A.M. Brady, C. McCabe & M. McCann (Eds.), Fundamentals of Medical-Surgical Nursing: A Systems Approach (pp. 469- 477). Dublin, Ireland: Wiley Blackwell.

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NursingBird. "Patient History and Examination: Jessica Case." March 28, 2021.