Patient History Examination
There is insufficient information considering the patient’s or her family’s medical history.
The present illness history: Jessica is a 32-year-old math teacher who experienced a sudden decrease in vision in her left eye on the day of her visit to the ER. Although the sickness was unexpected, Jessica had experienced blurred vision a month prior, with the assumption that overheating caused this medical complication. She currently has pain during eye movement and cannot differentiate colors. In summary, Jessica requires medical intervention to mitigate the consequences of the disease and improve her vision.
Reported Condition
The following information is based on the patient’s report, meaning that not all of the conditions are necessarily objective. Considering the cause of the problem, the patient denies any exposure to chemicals or physical injury. Consequently, she denies fever, chills, weight loss, fatigue, headache, sore throat, nasal congestion, neck pain, chest pain, abdominal pain, diarrhea, constipation, swelling in the legs, polyuria, polyphagia, and several other conditions. This information is helpful in determining the presumptive diagnosis.
Physical Examination
The physical examination revealed the following physical characteristics. BP 135/85 (high blood pressure), HR 64 regular bpm (normal), RR (respiration rate) 16 per minute (normal), T 98.5F (normal). The 12th cranial nerve is intact; horizontal nystagmus is present. Multiple other physical characteristics are within normal range, including muscle tone and reflexes. Visual acuity in the left eye is 20/200, which could be defined as legal blindness (“Common eye disorders and diseases,” 2022). Additional physical characteristics concerning vision include white sclera, clear conjunctivae, diminished response to light in the left eye, and swollen optic disc. The right eye presents normal functions with no apparent complications.
Consequently, the physical examination revealed the following behavioral characteristics. The patient is alert and anxious, which could be explained by the sudden complications in visual ability. She is oriented x 3, meaning that Jessica clearly understands the current location/date and who she is. Motor movement is normal (normal finger to nose).
Common eye disorders and diseases include refractive errors, age-related issues, cataracts, diabetic retinopathy, glaucoma group, amblyopia, strabismus, and neural complications (“Common eye disorders and diseases,” 2022). In this context, the diseases in glaucoma and optic neuropathy categories can be difficult to distinguish due to the common variable of nerve damage. In the current case, the presumptive nursing diagnosis is optic neuritis.
Presumptive Nursing Diagnosis
Optic neuritis is a common eye disease that can cause severe vision loss and restrict the visual field. It is an inflammation of optic nerves, and the exact diagnosis depends on the type of damage (Bennett, 2019). Therefore, there is a large variety of associated diseases and disorders that might deviate due to differences in the severity of visual loss, location of optic nerve damage, and causes of the issue (Bennett, 2019). Moreover, this variation is the reason for the confusion in the glaucoma and optic neuropathy categories, which can lead to false diagnoses (Solli et al., 2022). Therefore, while the symptoms indicate a variant of optic neuritis, more thorough examination is required to determine the exact diagnosis.
Optic neuritis is a common eye disease that can cause severe vision loss and restrict the visual field. It is an inflammation of optic nerves, and the exact diagnosis depends on the type of damage (Bennett, 2019). Therefore, there is a large variety of associated diseases and disorders that might deviate due to differences in the severity of visual loss, location of optic nerve damage, and causes of the issue (Bennett, 2019). Moreover, this variation is the reason for the confusion in the glaucoma and optic neuropathy categories, which can lead to false diagnoses (Solli et al., 2022). Therefore, while the symptoms indicate a variant of optic neuritis, more thorough examination is required to determine the exact diagnosis.
There are a few reasons why optic neuritis is the presumptive diagnosis. First of all, most of the mentioned symptoms are present in Jessica’s condition, particularly notable visual field loss only in one eye, swollen optic disc, and pain during one eye movement. According to Petzold et al. (2022), these signs and one paraclinical test provide sufficient justification for a “definitive optic neuritis” diagnosis. However, to determine the exact classification for optic neuritis, additional laboratory tests and examination are required.
The last factor that can potentially influence the choice of diagnosis is the cause of the disorder. For instance, optic neuritis might be a part of multiple sclerosis (MS), which is predominant in young females such as Jessica (Bennett, 2019). Moreover, optic neuritis emerges in approximately 25% of all patients suffering from MS (Zafeiropoulos et al., 2021). While it is not the only cause of optic neuritis, the risk factors suggest this possibility. Ultimately, it is essential to conduct additional laboratory tests to establish the exact diagnosis and classification.
References
Bennett, J. L. (2019). Optic neuritis. Continuum, 25(5), 1236. Web.
Common eye disorders and diseases. (2022). Centers for Disease Control and Prevention. Web.
Petzold, A., Fraser, C. L., Abegg, M., Alroughani, R., Alshowaeir, D., Alvarenga, R.,… & Plant, G. T. (2022). Diagnosis and classification of optic neuritis. The Lancet Neurology. Web.
Solli, E., Doshi, H., Elze, T., Pasquale, L., Wall, M., & Kupersmith, M. (2022). Archetypal analysis reveals quantifiable patterns of visual field loss in optic neuritis. Translational Vision Science & Technology, 11(1), 27-27. Web.
Zafeiropoulos, P., Katsanos, A., Kitsos, G., Stefaniotou, M., & Asproudis, I. (2021). The contribution of multifocal visual evoked potentials in patients with optic neuritis and multiple sclerosis: A review. Documenta Ophthalmologica, 142, 283-292. Web.