Eye Assessment and Primary Care of Adults Case Study

Patient Information

The patient initials are G.J., 54 years of age, female and of the Asian American race. She has had an irritation on the left eye.

History of Presenting Illness

The 54-year-old Asian American female presented with complaints of left eye irritations which started three days ago. The eye discomfort is characterized by a sharp and intermittent pain associated with blurred vision, photophobia, and headache which worsen with prolonged use of a computer. She rates the severity of the irritation at 8/10. No treatments were tried.

Current Medications

• Omeprazole 20mg, PO once per day (gastritis).
• Amlodipine 10mg P.O., once a day (hypertension).
• Lopid 600mg P.O., at bedtime (hypercholesteremia).
• Losartan 50mg PO, once a day (hypertension).
• Penicillin 500mg P.O., three times a day (pain).

Allergies

The patient has not known any drug or food allergies. However, she has seasonal allergies.

Past Medical History

The patient has a history of hypertension and gastritis. She is currently undergoing medications for these conditions. Her past visual record consists of complaints of eye pain. Her previous hospitalization was due to left breast bone discomfort which she received treatment. She has a history of colonoscopy surgery. The patient’s immunization history is up to date with the tetanus toxoid vaccine received during infancy.

Social History

The patient is married with two children who are alive and healthy. She denies having a history of cigarette smoking or alcohol consumption. The client is a retired teacher. She also reports tying her seat belt each time she travels.

Family History

History of diabetes, hypertension and cancer in her first-degree relatives.

Review of Systems

• General:
  • No fatigue or weakness;
  • Normal appetite;
  • Denies experiencing weight loss.
• Heent:
  • Reports having headache;
  • Reports blurry vision;
  • No hearing loss or ringing in the ears;
  • No mouth problems.
• Skin:
  • No skin rashes or itching;
  • Denies having dry skin.
• Cardiovascular:
  • No chest pain or chest discomfort;
  • Reports are measuring her blood pressure daily.
• Respiratory:
  • No difficulties in breathing.
  • Reports having a cough.
• Gastrointestinal:
  • Reports having upper gastrointestinal pain.
  • Denies having weight losses.
• Genitourinary:
  • Reports experiencing pain while urinating.
  • No memory of her last menstrual period.
• Neurological:
  • Reports headache.
  • Denies having loss of consciousness.
• Musculoskeletal:
  • No muscle stiffness.
  • Reports back pain and joint pain.
• Hematologic:
  • No anemia.
  • Denies having episodes of bleeding or bruising.
• Endocrinologic:
  • Denies history of the night sweating.
  • Denies cold or heat intolerance.
• Allergies:
  • Reports having a running nose.
  • Reports reddening of eyes.

Objective Assessment

The general assessment shows that the patient appears well-nourished, and appropriately dressed. The vital signs during examination are BP 126/86, pulse rate of 189, oral temperature of 98.8 fahreinheights, non-labored R.R. of 18, and SpO2 of 96% room air.

• Head: the head is rounded and symmetrical. Hair is thick and evenly distributed on the scalp. No shingles or scars were noted.
• Eyes: The conjunctiva appears reddened. The pupil is dark, equally round, and reactive to light. The assessment of the visual acuity is 20/20 showing a good vision. The presence of tears in the eyes was noted. The eyes are bilaterally symmetrical in size and shape. The patient can turn her eyes in all directions.
• Mouth: the lips are pink in color with no dryness. No dentures.
• Ears: no abnormal discharge noted. The sense of hearing is intact.
• Neck: no jugular vein distension or enlarged cervical lymph nodes.
• Chest: rises and falls with respirations. On auscultation of the heart, s1 and s2 sounds were heard with no extra heart sounds. Lung sounds are clear.
• Abdomen: no scars or organomegaly observed.

Differential Diagnoses

Seasonal allergic conjunctivitis is caused by seasonal allergens, including dust or pollen grains which stimulate histamine production due to mast cell degranulation causing itchy eyes, and reddening of the eyes edema of eyelids (Bielory et al., 2020).

Acute allergic conjunctivitis: A self-limiting inflammation of the conjunctiva occurs when it comes into contact with allergens, including animal dander causing an immunoglobin E-mediated reaction resulting in itchy eyes and swollen eyelids.

Dry eye syndrome: This condition is caused by the lack of tears leading to reduced lubrication in the eyes, causing itchiness.

My primary diagnosis is seasonal allergic conjunctivitis. This is due to symptoms of itchiness of the eyes, reddening of the eyes, and a positive history of seasonal allergies from the patient similar to the seasonal allergic conjunctivitis presentation.

Plan

Pharmacologic therapy involves the use of corticosteroids, lubricants, antihistamines, and mast cell stabilizers are effective (Chua et al., 2017). Mast cell stabilizers, including cromolyn sodium 200mg four times a day for 14 days. Topical antihistamines, including the application of antazoline twice daily. Topical NSAID, including diclofenac sodium, twice daily (Yeu et al., 2020). Systane solution 1 drop to each eye twice daily for 30 days for dry eyes.

Further management involves avoiding contact with the offending allergen by using glasses. Also, advise the patient to avoid rubbing her eyes as it causes mast cells degranulation. Furthermore, she can use cold compresses to relieve the itching (Shen et al., 2020). Further referral to an optometrist to evaluate the eyesight and perform an eye exam and offer specialized treatment is required. Follow-up is scheduled after three months.

Reflection

I agree with the preceptor’s treatment of the condition. This is because it addresses the resolution of the chief complaint of the patient. Using the mast cell stabilizers will reduce the body’s hypersensitive reactions to the allergens (DeWit et al., 2016). I learned the inherent value of in-depth history taking and physical examination in diagnosing an eye illness. The elderly client needs to be taught the avoidance of allergens like pollen and dust.

References

Bielory, L., Delgado, L., Katelaris, C. H., Leonardi, A., Rosario, N., & Vichyanoud, P. (2020). ICON: Diagnosis and management of allergic conjunctivitis. Annals of Allergy, Asthma & Immunology 124(2), 118–134. Web.

Chua, J., Lim, B., Fenwick E., Gan, A., Tan, A., Lamoureux, E. (2017). Prevalence, risk factors, and impact of undiagnosed visually significant cataract: The Singapore epidemiology of eye diseases study. PLoS ONE 12(1): e0170804. Web.

DeWit, S. C., Stromberg, H., & Dallred, C. (2016). Medical-surgical nursing: concepts & practice. Elsevier Health Sciences.

Shen Lee, B., Kabat, A. G., Bacharach, J., Karpecki, P., & Luchs, J. (2020). Managing dry eye disease and facilitating realistic patient expectations: A review and appraisal of current therapies. Clinical Ophthalmology, 14, 119–126. Web.

Yeu, E., & Hauswirth, S. (2020). A review of the differential diagnosis of acute infectious conjunctivitis: Implications for treatment and management. Clinical Ophthalmology, 14, 805–813. Web.