Subjective
- Chief Complaint: sudden decrease of vision in the patient’s left eye.
History of Present Illness (HPI)
- Jessica, a 32-year-old female, developed blurred vision in her left eye in the morning. Progressive deterioration occurred over the past few hours.
- Denies traumas, injuries, tearing, redness, and exposure to chemicals.
- Experienced blurred vision a month ago, supposedly related to overheating.
- Complaints of pain if the patient tries to move her eye; no pain when at rest. Problems with color determination.
Past History
- Past medical history: No chronic health conditions. No surgical history.
- Social history: Denies any history of smoking. Reports occasional drinking of wine 2-3 times a month.
- Psychiatric history: No depression, phobia, insomnia.
- Family history (FH): Mother – aged 57; hypertension. Father – aged 60; osteoarthritis.
- Medications & indications: None.
- Allergies: Denies drug, food, seasonal, environmental allergies.
- Immunizations: Up to date.
Health Promotion/Health Maintenance
- Readiness for enhanced nutrition.
- Readiness for Enhanced Spiritual Well Being
- Readiness to include treatment regimen in daily living.
- No family conflicts.
- No economic disadvantage.
Screenings/Exams
- Physical examination.
- Eye examination.
- The light test.
- Color differentiation test.
- Mental status examination.
Review of Systems
- Constitutional/general: No fever, chills, night sweats, weight loss, fatigue, headache.
- Eyes: Blurred vision in the left eye developed in the morning with subsequent deterioration within the past hours. Eye pain when moving. No trauma or injury. No tearing or redness.
- Ears/nose/mouth/throat: No changes in hearing. No discharge, obstruction, sinus pain, nasal or sinus congestion. No dental problems. No sore throat.
- Cardiovascular: No dyspnea, chest pain, palpitations, or hypertension. No exercise intolerance.
- Respiratory: No cough, wheezing, or trouble breathing.
- Gastrointestinal/abdomen: No abdominal pain, diarrhea, or constipation.
- Genitourinary: No dysuria, vaginal discharge, or polyuria.
- Musculoskeletal: No neck pain or stiffness. No swelling in the legs. No arthritis.
- Integumentary: No rashes or itching. No skin discoloration, dryness, or easy bruising. No hair loss. Or changes in hair and nails.
- Neurological: No headaches, seizures, loss of consciousness, or weakness. No tremor, incoordination, or muscle spasm.
- Psychiatric: Positive for anxiety. No depression or suicide ideation. No memory loss, sleep problems.
- Endocrine: No polydipsia or polyphagia. No thyroid problem, excessive sweating, or diabetes. Reported blurred vision a month ago, attributes to being overheated; vision improved in a cool, air-conditioned environment.
- Hematologic/lymphatic: No anemia. No easy bruising. No past transfusions.
- Allergic/immunologic: No asthma, hives, swelling of lips or tongue. No eczema.
Vital Signs
- The patient is alert, well-oriented. Appears anxious.
- BP 135/85 mm Hg.
- HR 64bpm and regular.
- RR 16 per minute.
- T: 98.5F.
Physical Exam
Eye examination:
- Visual acuity of 20/200 in the left eye and 20/30 in the right eye. Sclera white, conjunctivae 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.
Mental status examination:
- Oriented x 3. Cranial nerves: I-XII intact; horizontal nystagmus is present. Muscles with normal bulk and tone. Normal finger to nose, negative Romberg. Intact to temperature, vibration, and two-point discrimination in upper and lower extremities.
- Reflexes: 2+ and symmetric in biceps, triceps, brachioradialis, patellar, and Achiles tendons. No Babinski.
Assessment
- Diagnosis (Dx): Optic neuritis.
- Differential diagnoses: Neuromyelitis optica; Ischemic optic neuropathy; Granulomatosis with polyangiitis (Wegener granulomatosis); Central serous retinopathy; Functional vision loss.
- Optic neuritis implies decreased vision in one of the patient’s eyes, pain with eye movement, and temporary colorblindness (Chen et al., 2020).
- The causes remain unknown, although they might be related to immune system attacks (Chen et al., 2020).
- This optic neuropathy often affects young adults and is characterized by the sudden development.
Plan/Treatment
- To reduce the harmful effects on the patient, rest and a harmless environment should be provided to Jessica to avoid injury or traumas.
- It is recommended to watch out for and identify new symptoms if they occur.
- Visual impairment requires the patient to stay under the nurse’s supervision (Ackley et al., 2017).
- Avoiding eye movement and electronic devices is recommended to decrease pain.
- Optic neuritis can improve without any medical interference; however, the patient should be informed of the risks and causes.
References
Ackley, B. J., Ladwig, G. B., & Makic, M. B. (2017). Nursing diagnosis handbook: An evidence-based guide to planning care (11th ed.). Elsevier.
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.