6

Comprehensive Clinical Note #2

Scholastica Tandongfor

Rocky Mountain University

FNP 710

17th November 2023

Patient Information:

P.J

Age: 33 years

Sex: Male

Race: African American

S.

CC (chief complaint): Severe headache, blurred vision and photophobia.

HPI: P.J, a 33-year-old African American male patient comes to the hospital with complains of severe headache, blurred vision and photophobia. Peter James states that his symptoms started five days ago when he started having frontal headache, blurred vision and photophobia. He also states that he experienced pressure around his eyes and the headache was continuous. Peter also reported that the headache was exacerbated when he walked around. Resting or sleeping helped to relieve the headache. When asked to rate the severity of the headache on a scale of 10, he rated the headache at a score of 7/10.

Current Medications: Peter is not on any current medication.

Allergies: He is not allergic to any drug. Allergic to cats where he reports having a runny nose. Not allergic to any food.

PMHx: Peter has never suffered from any major or serious illness. Has a surgical history where she underwent surgery to correct left fracture femur after an accident in 2019. Last Tetanus toxoid vaccine in the year 2021. Covid 19 vaccine on 21st July 2021 (Moderna.) Booster dose on 3rd January 2022.

Soc Hx: Peter is a software developer who works in one of the IT companies in town. He states that he likes spending most of her time with his laptop trying to invent various software applications. He states that during his free time, he likes watching series and movies. He does not smoke, drink or use any recreational drug. Married with two sons. Lives with the family in an apartment in town where the neighborhood is safe.

Fam Hx: Father has hypertension, heart failure and diabetes. Mother has hypertension. Both patents are still alive. Reports that the brother also has hypertension and peptic ulcer disease. The sister is well with no any chronic condition.

ROS:

GENERAL: No weight loss, weakness, or fatigue. There is no fever of chills.

HEENT: Head: patient reports of headache that started five days ago. There is no head injury of trauma. Eyes: blurred vision, photophobia and pressure around eyes. Ears, Nose, Throat: there is no hearing loss or abnormal discharge from the ears. No nasal congestion and no sore throat.

SKIN: skin moist with no rashes, wounds or bruises.

CARDIOVASCULAR: No palpitations, chest pain, chest pressure or chest discomfort. No edema of the lower limbs.

RESPIRATORY: No cough, shortness of breath or sputum.

GASTROINTESTINAL: No vomiting, nausea or any diarrhea. No abdominal pain.

GENITOURINARY: No dysuria, urgency, and frequency during urination. No irritation when urinating.

NEUROLOGICAL: The client complains of headache with blurred vision and photophobia. No ataxia. No tingling sensation at the extremities. Normal bladder and bowel control.

MUSCULOSKELETAL: No muscle pain. No joint pain. History of left fracture femur after an accident.

HEMATOLOGIC: No anemia, bleeding or bruising.

LYMPHATICS: No enlargement of lymph nodes. No history of splenectomy.

PSYCHIATRIC: No history of anxiety or depression. No history of suicidal ideas or thoughts.

ENDOCRINOLOGIC: No heat or cold intolerance. No polydipsia or polyuria. Not diabetic.

ALLERGIES: Allergic to cats where he experiences runny nose. Not allergic to any drug or food. No history of asthma.

O.

Physical exam:

General: The patient is alert. She is well oriented and well groomed.

Vital signs: Temperature-98.2, BP: 130/78, HR: 77, clear and regular RR: 20, unlabored. Weight: 120 lb. (54.3kgs) BMI: 23

HEENT: Head: normocephalic head with no injury or trauma despite headache. Hair is well distributed on the head. Eyes: There is pressure or swelling around the eyes. No abnormal discharge from the eyes. no redness. blurry vision, flashes, and photophobia. Visual acuity V(left eye) 23/60, and V(right eye) 19/60.

Ears: Ears are symmetrical with no abnormal discharge. The tympanic membrane intact. No hearing problems noted.

Nose: No nasal polyps or abnormal discharge from the nose. Normal septum with normal sinuses.

Throat: No difficulty in swallowing. No occlusion.

Upper arm: both arms are equal and symmetrical. No deformity was noted.

Diagnostic results:

Visual acuity: this will help assess the vision of the patient. The test checks how the patient sees symbols of letters from a determined distance (Li et al., 2021).

Ocular Tonometry: this is a test done to determine the intraocular pressure to identify patients at risk of glaucoma (Schick, Heimann & Schaub, 2020).

Physical examination and history taking will also help in diagnosing the patient.

A

.

Differential Diagnoses:

Retinal detachment

Retinal detachment is the primary diagnosis in this case. It refers to an emergency where the retina detaches from its supportive tissues (Schick, Heimann & Schaub, 2020). This interferes with supply of nutrients and oxygen to the eye. Signs and symptoms of retinal detachment include appearance of floaters, blurred vision, flashes of light, photophobia and headache (Li et al., 2021). Patients may also experience tunnel vision, redness and dilated pupils. In this case, the client presents with blurred vision, photophobia and severe headache and therefore he is more likely to be having retinal detachment. A thorough history taking, physical examination and proper eye tests will help in diagnosing retinal detachment (Schick, Heimann & Schaub, 2020).

Glaucoma

Glaucoma refers to a group of eye problems that damage or affect the optic nerve. Damage to the optic nerve leads to loss of vision or blurred vision. In glaucoma, fluid may accumulate in the eye leading to eye pressure or intraocular pressure that damage the optic nerve. Common signs and symptoms of glaucoma include eye pain, eye pressure, visual disturbance, nausea, blurred vision and vision loss (Schick, Heimann & Schaub, 2020). The patient is presenting with blurred vision and eye pressure which may be symptoms of glaucoma. However, photophobia rules out glaucoma as the main diagnosis. Ocular tonometry in this case will help diagnose or rule out glaucoma.

Ocular hypertension

A condition where pressure inside the eye or intraocular pressure is greater than the normal pressure. Signs and symptoms include blurred vision, eye and halos. Unlike in glaucoma, there is no damage to the optic nerve in ocular hypertension (Sultan et al., 2020). The client in the care has eye pressure and blurred vision. This makes ocular hypertension a possible diagnosis. Optic tonometry and measuring the intraocular pressure and assessing the optic nerve will help rule out ocular hypertension as the diagnosis. Hypertension is also associated with eye pressure, headache and blurred vision.

P.

1.
Additional diagnostic studies.

Ultrasound imaging of the eye: this will help to visualize any sign of bleeding in the eye and to note the extend of detachment of the retina (Li et al., 2021).

CT scan of the eye: to help visualize if there is damage to the retina.

MRI of the eye: to identify any pressures of the eye and damage to the optic nerve.

2.
Therapeutic interventions:

1g paracetamol TID for three days for the headache.

Vitrectomy a surgical procedure to replace the eye jelly (Schick, Heimann & Schaub, 2020).

Laser surgery: to repair the detached retina.

Freezing (cryopexy): to secure the retina to the walls of the eye (Schick, Heimann & Schaub, 2020). 

3.
Referrals

Ophthalmologist: to help in diagnosing and managing the patient.

Neurologist: to help detect if there is any damage to the optic nerve.

4.
Education and Health promotion

Adherence to medications and treatment plan for better outcomes.

Avoid rubbing your eyes with hands.

Observe hand hygiene and ensure clean and safe environment.

Avoid bright lights and screens. Use eye protection such as glasses when using screens (Sultan et al., 2020).

Eat a well-balanced diet.

5.
F/U and rational:

One week to assess progress of treatment plan.

Reflection

The case has enabled me to learn a lot about eye conditions and how to manage eye conditions. In this case, I was able to learn about retinal detachment in details. Retinal detachment is a condition where the retina detaches itself from the eye’s connective tissues. Conditions that mimic retinal detachment include glaucoma, ocular hypertension and cataract. A thorough history taking and physical examination with emphasis on the eyes is essential in diagnosis of eye conditions (Cassel, 2021). Tests such as visual acuity and tonometry help in diagnosing eye problems.

I agree with the preceptor’s diagnosis and treatment of the patient. The history and test results indicate that the patient has retinal detachment. Paracetamol will help reduce the patient’s headache. The best intervention as stated by the preceptor is surgical intervention to repair the detached retina. Early treatment prevents loss of vision (Sultan et al., 2020). Prevention includes working in a safe environment and using protective glasses while engaging in any risky activity. People should observe high hand hygiene and avoid rubbing their eyes frequently. The thing that I would do differently is to asses signs of diabetes and hypertension complications since they also lead to eye problems.

References

Cassel, G. H. (2021). 
The eye book: a complete guide to eye disorders and health. JHU Press.

Li, K. X., Carducci, N., Moinuddin, O., Zhou, Y., Musch, D. C., Zacks, D. N., … & Wubben, T. J. (2021). Contemporary management of complex and non-complex rhegmatogenous retinal detachment due to giant retinal tears. 
Clinical Ophthalmology (Auckland, NZ), 
15, 1013.

Schick, T., Heimann, H., & Schaub, F. (2020). Retinal Detachment Part 1-Epidemiology, Risk Factors, Clinical Characteristics, Diagnostic Approach. 
Klinische Monatsblatter fur Augenheilkunde.

Sultan, Z. N., Agorogiannis, E. I., Iannetta, D., Steel, D., & Sandinha, T. (2020). Rhegmatogenous retinal detachment: a review of current practice in diagnosis and management. 
BMJ open ophthalmology, 
5(1), e000474.