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Sudden Decrease of Vision in the Patient’s Left Eye: Case Study

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.

Review of Systems

  • 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:

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  • 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.

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StudyCorgi. "Sudden Decrease of Vision in the Patient’s Left Eye: Case Study." July 13, 2022. https://studycorgi.com/sudden-decrease-of-vision-in-the-patients-left-eye-case-study/.

References

StudyCorgi. 2022. "Sudden Decrease of Vision in the Patient’s Left Eye: Case Study." July 13, 2022. https://studycorgi.com/sudden-decrease-of-vision-in-the-patients-left-eye-case-study/.

References

StudyCorgi. (2022) 'Sudden Decrease of Vision in the Patient’s Left Eye: Case Study'. 13 July.

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