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Physical Assesment Case Study 2

Physical Assesment Case Study # 2
Instructions:

Case Study II

Jessica is a 32 y/old math teacher who presents to the ER with a friend for evaluation of sudden decrease of vision in the left eye. She denies any trauma or injury. It started this morning when she woke up and has progressively worsened over the past few hours. She had some blurring of her vision 1 month ago and thinks that may have been related to getting overheated, since it improved when she was able to get in a cool, air-conditioned environment. She has some pain if she tries to move her eye, but none when she just rests. She is also unable to determine colors. She denies tearing or redness or exposure to any chemicals. Nothing has made it better or worse.

She is normally healthy. She had chickenpox at age 10 and a tonsillectomy/adenoidectomy at age 11. She has no medical problems. She has never been hospitalized. She has four children, all spontaneous vaginal deliveries. She completed a bachelor’s degree in mathematics and a master’s degree in education. She quit smoking 10 years ago (two packs daily for 5 years); she drinks an occasional wine cooler, and she denies illicit drug use. Her father has a coronary artery disease (he had a stent placed at age 67) and a mother with hypertension.

She denies fever, chills, night sweats, weight loss, fatigue, headache, changes in hearing, sore throat, nasal or sinus congestion, neck pain or stiffness, chest pain or palpitations, shortness of breath or cough, abdominal pain, diarrhea, constipation, dysuria, vaginal discharge, swelling in the legs, polyuria, polydipsia, and polyphagia.

Patient is alert; she appears anxious. BP 135/85 mm Hg; HR 64bpm and regular, RR 16 per minute, T: 98.5F. Visual acuity 20/200 in the left eye and 20/30 in the right eye. Sclera white, conjunctivae clear. Unable to assess visual fields in the left side; visual fields on the right eye are intact. Pupil response to light is diminished in the left eye and brisk in the right eye. The optic disc is swollen. Full range of motions; no swelling or deformity. Mental status: Oriented x 3. Cranial nerves: I-XII intact; horizontal nystagmus is present. Muscles with normal bulk and tone; Normal finger to nose, negative Romberg. Intact to temperature, vibration, and two-point discrimination in upper and lower extremities. Reflexes: 2+ and symmetric in biceps, triceps, brachioradialis, patellar, and Achiles tendons; no Babinski.

Instructions:

Complete a comprehensive history and Physical Examination

What physical findings are you looking for to help determine a presumptive nursing diagnosis?

Nursing Care Plan and teaching plan.

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