Question

Chief Complaint A 52 y.o. accountant presents to the clinic with a sudden onset of right eye pain and redness. He believes something must have gotten in his eye while he was clearing brush in his backyard yesterday. No pain was noted during that time, but he awoke early this morning, and the pain started within an hour. He wears contact lenses and has removed them without relief. He has no history of eye problems other than farsightedness, for which he has worn monovision contact lenses for 10 or more years. He has no known medical problems and considers himself “very healthy.” He says the pain was horrible at first (10/10) and now is slightly less (8/10) but still bad. He said although he removed his contacts and his vision is generally similar in both eyes, his vision in his right eye is very blurry.

Physical Examination

• Vital signs: T 98.4, BP 150/95, HR 88, RR 18, HT 70, WT 215 lbs.

• General: Patient holds right eye constantly during history and appears in distress.

• Vision: Visual acuity, uncorrected: OS 20/60; 0D less than 20/200. Eye movements briefly assessed to be symmetrical. Pupillary responses—OS brisk and responsive; OD fails to constrict although poor tolerance of exam. OS normal structures, no lesions, redness, conjunctiva intact. OD eye is reddened and some watery tearing noted. No foreign body visible. OS funduscopic exam within normal limits. OD funduscopic exam not tolerated.

Case Study Discussion – Part I:

Answer the following and post your response in the Case Study Part I by creating your own initial thread.

Identify three conditions that you would consider in your differential diagnosis, with the most likely condition listed first. Provide rationale for each differential with supporting evidence from the case study.

What further history, further examination, and diagnostic studies should be considered in order to explore your differential diagnosis and confirm your suspicions?

Case Study Discussion – Part II:

Answer the following and post your response as an additional response to your original Part I thread.

Reflecting back on your previous post, how successful were you in identifying the possible diagnosis? What aspects from the case study were the most relevant in order to help confirm this diagnosis? Why does this patient need to be referred to the ophthalmologist immediately? Support your plan of care by incorporating evidence based rationale practice.

Answer 1

Case Discussion Part 1:

Differential Diagnosis:

• Corneal abrasions: It is scratch off the eye caused by dust, sand, fingernails, or rubbing. The symptoms include redness, eye pain, tearing, blurred vision.
• Uveitis: It is eye inflammation that occurs suddenly which affects the middle layer of the eye. Eye redness, eye pain, and light sensitivity are common symptoms.
• Conjunctivitis: Conjunctivitis leads to inflammation of the eye caused by allergies. removal or improper contact lens may also lead to conjunctivitis.

History:

• Collect past medical history of chronic diseases like diabetes, hypertension.
• Collet history of his immediate surroundings.
• Collect a history of eye findings.
• Collect a history of environmental exposure.

Physical Examination:

• Examine the eye for swelling, redness.
• Examine for any injury.
• Examine for the presence of foreign materials.

Diagnosis:

• A lab test of CBC to analyze the blood cell count.
• PT, INR test to detect blood clotting factors and diagnose of hemorrhage.
• Photography to analyze the retinal blood flow.
• analyze of eye fluid.