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Right eye pain (1)
- 1. Right Eye Pain Case Study Analysis Manisha Darden, Amber Banks, Anita Martinez, Danielle Choate, and Tosha Thomas-Floyd
- 2. The Presenting Problem 55-year-old c/o mild right eye pain and watery discharge for the past 24 hours without decline in vision.
- 3. Subjective Data Known Facts about Mr. E. • 55-year-old male • Occupation: Machinist • Eye pain described as “mild discomfort” for 24 hours • Watery discharge • No decline in vision • Denies work related exposures to eye injuries • Does not wear corrective lenses
- 4. Subjective Data Known Facts about Mr. E. cont’d • Denies surgical history • Denies seasonal allergies , recent nausea, vomiting, diaphoresis, or abdominal pain • History of hypertension managed by medication. • Regularly sees PCP • 40 pack-year history of smoking • Upper respiratory infection one week ago
- 5. Problem Statement This is a 55-year-old machinist complaining of mild right eye pain and watery discharge for the last 24 hours with no decline in vision. He has a history of hypertension and smoking. States he had a URI one week ago.
- 6. What do we need to do for Mr. E.? • Collect additional subjective and objective information. • Based on results, diagnose what is causing his eye symptoms. • Prescribe treatments/prescription medications as indicated. • If appropriate provide a referral to see a specialist such as an opthamologist or surgeon. • Offer education regarding eye safety, management of hypertension and smoking cessation.
- 7. Other Considerations • Access to care • Ability to be compliant with treatments/recommendations • Erikson’s stages of development: Generativity vs. Stagnation • Cultural or religious preferences that may affect treatment
- 8. Subjective Data What Eye’d Like to Know • What were you doing when you first noticed the pain? • Can you describe the characteristics of the pain? ie; onset, location, quality, intensity, and exacerbating or alleviating factors. • Is the discomfort constant or intermittent? • Does it feel like there is debris in your eye? • Have you noticed any redness or swelling? • Can you describe the characteristics of the discharge? ie; crusting or changes in color, consistency, amount.
- 9. Subjective Data What Eye’d Like to Know cont’d • Have you experienced any itching? • Have you noticed any difficulty opening or closing your eyes? • Are your eyes sensitive to light? • Are you noticing any visual changes such as blurriness, flashing lights or dark spots, crooked or wavy items in visual field? • Have there been any changes in your peripheral vision? • Are you to differentiate color and fine details?
- 10. Subjective Data What Eye’d Like to Know cont’d • Have you felt anything like this before? If so, was it diagnosed? As what? • Does anyone in your family or at work have similar symptoms? • When was your last complete eye exam with an ophthalmologist? Were any problems noted at that time? • Have there been any recent changes in your medications? • Are you noticing any other symptoms such as congestion, headache, fatigue, aching joints etc.? • Do you wear eye protection while at work?
- 11. Subjective Data Additional Information Needed • Obtain a full medical/surgical history • Gather a family history of relevant diagnoses • Assess personal and social history
- 12. Objective Data The Eyes Have It • Inspect the external eye, eyelids, lacrimal ducts, sclera, conjuctiva, cornea, and iris for color, drainage, swelling or ulcerations • Palpate the lacrimal sac and gland • Observe the extraocular muscles for function/symmetry • Assess the pupils for PERRLA • Perform an opthalmascopic exam to inspect the optic disc and retina • Test for visual acuity with Snellen Eye Chart
- 13. Possible Hypotheses, Actions, Recommendations, & Solutions Differential Diagnoses: • Corneal injury from abrasion or embedded foreign body • Iritis • Keratitis • Entropion
- 14. Corneal Injury Treatment/Plan Abrasion or Foreign Body • Removal of foreign body if superficial by flushing or use of cotton swab Diagnosed with eye • Referral to skilled practitioner for exam removal of embedded foreign body • Antibiotic drops or ointments • Topical cycloplegic for pain/photophobia • Pressure patch/bandage is not recommended unless damaged area is >10mm² **do not use patch if you suspect perforation, or if there my be some foreign body remaining
- 15. Iritis Treatment/Plan • Referral to an opthamologist if Diagnosed by slit lamp suspected exam • Cycloplegic drops to dilate pupil • Mild analgesics • Steroid eye drops • If severe, steroid injections • Treat the underlying cause if related to systemic disease * *glaucoma test performed to measure intraocular pressure if iritis is suspected
- 16. Keratitis Treatment/Plan • Topical, PO, or IV antibacterial, antifungal Diagnosed by vision or antiviral therapy (depending on cause) exam with a slit lamp • Artificial tears • Steroid drops • Referral to specialist for surgical removal of foreign body if found on examination • If wearing contact lens advise to stop • Collect culture or scraping from corneal surface if infection is suspected • Blood samples may be collected if health history reveals underlying disease may be to blame
- 17. Entropion Treatment/Plan • Artificial tears/lubricants Diagnosed by physical • Skin tape examination of eyes and • Botox eyelids • Teach eye hygiene/care • Referral to surgeon; eventually will need corrective surgery
- 18. SOAP Note • S: 55-year-old male machinist c/o right eye “mild discomfort” and watery discharge x 24 hours. Denies decline in vision. Denies use of corrective lenses. Denies work related exposures to eye injuries. Denies allergies or recent nausea, vomiting, diaphoresis, abdominal pain. States hx of HTN managed by medication. 70-pack-year smoker; 3 packs /day x 40 years. Denies surgical history. States upper respiratory infection one week ago. • O: This will be gathered in the patient assessment with thorough external and opthalmoscopic eye exam. • :
- 19. SOAP Note Objective Information • A: Corneal injurry r/t abrasion/embedded foreign body, Iritis, Keratits, Entropion • P: External eye/opthalmic exam. Prescriptions for medications as indicated based on diagnosis. Removal of foreign body if found to be on superficial surface of cornea or conjunctiva. Referral to opthamologist if indicated for embedded foreign body removal. Referral to surgeon if needed. Treat underlying systemic disease if causality found upon assessment. Provide education regarding the use of eye protection at work and smoking cessation.
Hinweis der Redaktion
- The original case study: Mr. E. is a 55-year-old machinist who comes to the office complaining of pain in his right eye for the past 24 hours. He describes the pain as a mild discomfort. He has also noticed a watery discharge. He has not noticed a decline in his vision. He does not wear corrective lenses. He denies any work-related exposures. He states he had an upper respiratory infection one week ago. He denies any seasonal allergies. He has a history of hypertension and sees his physician regularly for checkups; he has been told that his blood pressure is controlled by medication. He has not experienced nausea, vomiting, diaphoresis, or abdominal pain. Mr. E. has smoked three packs of cigarettes daily for 40 years. He has never had surgery.
- DischargeThe excretion of any substance from the eyes other than tears is known as a discharge. A common finding, discharge may occur in one or both eyes and may be scant or copious. The discharge may be purulent, frothy, mucoid, cheesy, serous, clear, or have a stringy, white appearance. Eye discharge commonly results from inflammatory and infectious eye disorders, such as conjunctivitis, but it may also occur in certain systemic disorders.PainEye pain may signal an emergency and requires immediate attention. Diseases causing eye pain include acute angle-closure glaucoma and conjunctivitis. Corneal damage caused by a foreign body or abrasions as well as trauma to the eye can also cause eye pain.
- We know very little about his eye pain, other than what the patient has stated. We know working as a machinist puts him at risk for eye injury from flying debris, so a thorough physical eye examination is needed.His history of smoking and hypertension also put him at risk for developing eye problems such as hypertensive retinopathy, so visual acuity will also be tested. 3 PACKS per DAY
- We need to further assess Mr. E’s ability to receive care and his compliance. He is employed and because he sees his doctor regularly, we can only assume he is insured or able to afford care. He states he is managing his hypertension with medication, so we can assume that he is compliant with his medications. At 55 he is at the end of the Erikson’s stage: Generativity vs. stagnation, therefore work and family would be his main priority if he is in the appropriate psychosocial category for his age. We are unsure of his race, ethnicity, or religious preferences, so it would be important to assess these needs before beginning the physical assessment.
- Was he at work? Driving? etc.
- Although Mr. E. states no decline in his vision or the need for corrective lenses, something to note is that hypertension can lead toarteriosclerosis of the retinal blood vessels and lead to impaired vision.It would be difficult for someone to notice a sudden decline in vision if his baseline acuity is already poor.
- Also include Family history :1. Myopia2. Cataracts3. Glaucoma4. Loss of visionPsychosocial history1. Finds out about daily habits that affect the eyes2. Reveals occupation and work environment - machinist3. Tells about smoking habits – smokes regularly for 40 yrs
- Because there is no objective data given in the case study, acomplete eye exam is needed on Mr. E. Before starting your examination, gather the necessary equipment, including a good light source, one or two opaque cards, an ophthalmoscope, vision-test cards, gloves, tissues, and cotton-tipped applicators. Make sure the patient is seated comfortably and that you're seated at eye level with him.
- Iritis:dx- exam eye with a slip lampshining light in unaffected eye will cause pain in affected eyeglaucoma test- pressure will be lower in affected eyepupil will be smaller and irregulartreatment/plan- eye drops to dilate pupilmild analgesiassteroid eye dropsif severe steriod injections
- Theslit lamp test will be performed by an opthamologist, If it shows white blood cells or a light reflection from in the anterior aqueous humor this is the “cells and flare” reaction that is found with iritis. Glaucoma and blindness can be the result of iritis if untreated.
- Keratitis can be viral, bacterial,or fungal. It can be caused by trauma, dry eyes, or an underlying systemic disease.
- botox is effective treatment of spastic entropion r/t weakening of ocularis musclessuture placementsurgical repair of entropion
- Patients with high blood pressure are at risk for arteriosclerosis of the retinal blood vessels and vision disturbances.