History of Present Illness (HPI)

32 y o ordinarily healthy complains of decreased vision in her left eye. According to her, she woke up this morning complaining of blurred vision which worsened as the day progressed. A month ago, she had blurred vision and linked it overheating and went away when the she was in a place that had free-air movement. She also complains of some pain whenever there is continuous eye movement. Although she is unable to tell colors, she does not report any tearing or exposure to chemicals. Her condition remains constant. Patient has not yet taken any medications today. 

Past Medical history

•    Normally healthy

•    Had chickenpox when she was ten years old

•    Has no medical problems

•    Never been hospitalized

Active medical problems

•    None

Surgical history

•    Had tonsillectomy at the age of 11

Family history

•    Patient has four children

•    She has had normal vaginal deliveries

•    She went through her bachelor’s degree in math and also has a master’s in education

Social history

•    Quit smoking a decade ago after smoking five packets of cigarettes daily for five years

•    Occasional wine drinker

•    Never done illicit drugs

•    Her father suffers from a heart condition known as the coronary artery disease

•    Father had a stent at the age of 67

• Mother is hypertensive

ROS

General- 

•    She does not complain of any fever, chills, weight loss, hearing developments, itchy throat, headaches, congestion, chest pains, neck problems, difficulty in breathing, abdominal pain, coughs, diarrhea, vaginal discharge, constipation polydipsia, polyuria, fatigue, and polyphagia. 

•    Appears to be anxious

Eyes/Ears/Nose (ENT)- 

•    Blurred vision

Visual acuity in the left eye 

•    Normal vision in the right eye

•    Whitish discharge

•    Not in a position to assess optical vision on the left eye

•    The response of the left eye pupil to light is diminished in the left eye and normal in the right eye. 

•    Swollen optic disc

•    No deformity or swelling

•    Lacks vertigo, 

•   Negligible vision changes,

•    No eye pain. 

•    Full range of actions

•    No swelling or deformity

Throat

•    Patient denies any changes in taste or experiences of regurgitation

Skin: 

•    No rash or lesions

Cardiac

•    She denies reflux/heartburn.

•    No Recent chest pains

•    Normal breath

•    The patient had no palpations

Pulmonary: 

CTAB. Negative wheezes/rales/crackles

Abdomen: 

• No physical deformations
• Patient denies any masses or guarding

Mental Health

•    appears to be no depression or mood changes

•    Alert and oriented. 

•    She responds appropriately to questions.

Neuro: 

•    She denies any headaches. 

•    Fluent speech

•    Does not show any signs of tremor 

•     Normal strength.

•     Normal sensation.

Problem List

•    Blurred Vision

Assessment

This is a 30-year-old woman with significant eye problem with a decreased vision that has worsened within hours.

Differential Diagnosis of Decreased Vision

Given the patient’s MH and PE, it is likely that she has Optic Neuritis which is a demyelinating inflammation of the optic nerve (Beleznay et al, 2016). The patient also complains of a deficit is the color vision and brightness sensitivity, rapid development of impaired vision in one eye, change in color perception (Dyschromatopsia), ocular pain as a result of eye movement Uhthoff phenomenon caused by heat or exercise which are signs of inflammation of the optic nerve (Noseda & Burstein, 2013). She has no other physical complains such as headaches, nausea, vomiting, difficulty in movement, skin color changes or rashes. Although her previous smoking would account for her symptoms, it is unlikely. As such, the presentation reflects symptoms for multiple sclerosis (MS) as well as neuromyelitis optica (NMO).

Patients with MS are likely to have recurrent attacks of the Optic Neuritis (Noseda & Burstein, 2013). This implies that an episode of a past event of decreased vision in the same eye may be elicited. In addition, NMO shows symptoms of Severe bilateral; optic neuritis in a temporal moment or occasionally precede the myelopathy.

Nursing Care Plan

A funduscopic should be carried out to establish the dilation of the pupil. With a period of 2-6 hours, use 2.5% phenylephrine and 1% tropicamide. It is essential to examine the red reflex of each eye before examining the retinal and optic nerve features (Ivarsen, Asp & Hjortdal, 2014). The quality of the red reflex determines the indication of the limits of the visual impairment as a result of media opacities. For the blurry vision, the patient should be maintained on Phenylephrine and tropicamide. By administering Aspirin, it inhibits the formation of cyclooxygenase hence, preventing thromboxane A2 which is a platelet aggregator as well as vasoconstrictors. The inhibition of platelet formation lasts for ten days which is equal to cell life. When the patient is given Dipyridamole, it helps to prevent the platelets from holding together thus, inhibiting the uptake of adenosine which suppresses platelet reactivity (Ivarsen, Asp & Hjortdal, 2014). In addition, it may avoid Phosphodiesterase activity that leads to increased cyclic 3’, 5’ Adenosine monophosphate.

Dispo:

 Discharge the patient and outpatient follow up

References

Beleznay, K., Carruthers, J. D., Humphrey, S., & Jones, D. (2015). Avoiding and treating 

blindness from fillers: a review of the world literature. Dermatologic Surgery, 41(10), 1097-1117.

Ivarsen, A., Asp, S., & Hjortdal, J. (2014). Safety and complications of more than 1500 small-

incision lenticule extraction procedures. Ophthalmology, 121(4), 822-828.

Noseda, R., & Burstein, R. (2013). Migraine pathophysiology: anatomy of the trigeminovascular pathway and associated neurological symptoms, cortical spreading depression, sensitization, and modulation of pain. PAIN®, 154, S44-S53.