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

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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:

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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