Subjective
- Chief Complaint: A 32-year-old woman was admitted with a short history of visual acuity in the left eye lasting for a couple of hours.
- History of Present Illness: Jessica, a math’s teacher, had suffered a blurred vision related to getting heated,
- This condition improved when she got in a cool, air-conditioned environment.
- The patient experienced pain while moving her eye, but none when she rests.
- She was also unable to detect colours.
Past History
- Past medical history: The patient had suffered from a blurred vision that improved without being hospitalized.
- Social history: Mrs Jessica is a teacher with no history of alcohol or use of cigarette.
- Psychiatric history: She is always alert and active.
- Family history: The patient had no record of diseases.
- Medications & indications: She had not received any form of medication.
- Allergies: The patient denied any form of allergy.
- Immunizations: Apart from childhood immunization, she had not received other forms of vaccination.
Health Maintenance
- The patient mentioned a healthy diet
- She rests when her condition is unwell.
- She exercises regularly.
- The patient does not visit medical check-up.
- The patient does not receive immunization.
Screenings
- Jessica denied chills, fever, weight loss, and fatigue.
- She denied night sweats, and polydipsia.
- She denied polyuria, nasal congestion, and swelling in the legs.
- She denied changes in hearing, vaginal discharge, and dysuria.
- She denied abdominal pain, headache, and sore throat chest pain.
Review of Systems
- Constitutional: The patient was alert but appeared anxious.
- Eyes: She had 20/200visual acuity and 20/30 visual acuity in the left and right eye, respectively. The pupil in her left eye responded slowly to light while the one in the right eye was brisk.
- Ears/nose/mouth/throat: She had normal mouth, throat, no epistaxis, or hearing problems.
- Cardiovascular: The patient presented intact I-XII in the cranial nerves, horizontal nystagmus, and normal muscles.
- Respiratory: She had no history of cough, pleurisy, asthma, hemoptysis, wheezing, or pulmonary.
- Gastrointestinal: The patient did not present melena, hematemesis, or endoscopy.
- Genitourinary: Had normal menstrual cycle and genitourinary organ.
- Musculoskeletal: Her muscles had normal bulk and tone.
- Integumentary: She had normal endoscopy and hematocrit.
- Neurological: Her cranial nerves had I-XII intact, and horizontal nystagmus.
- Psychiatric: She experienced anxiety.
- Endocrine: She did not present thyroid disease.
- Hematologic: She had no blood or clotting disorders.
- Allergic: She is not allergic.
Vital Signs
- The patient was alert but appeared anxious
- HR: 64bpm and regular
- RR:16 per minute
- T:98.5 0 C
- BP:135/85 mm Hg.
Physical Exam
- She had 20/200 and 20/30 visual acuity in the left and right eye, respectively.
- She presented clear conjunctivae and white sclera and could not detect visual fields on the left eye.
- She had intact visual fields on the right eye.
- Pupil in her left eye responded gradually to light while the right eye was brisk
- Apart from the blurred vision and anxiety, the patient had no symptoms.
Assessment
Possible Diagnosis
- Simple anisometropia – arises when one of the eyes has a refractive error.
- Refractive error – common among diabetic.
- Opacities of the ocular media – results in hemorrhage, and it is common among people with diabetes with abnormal retinal bleeding blood vessels.
- Retinal disorders – it is related to macular degeneration, common among aged people.
- Optic nerve disorder – manifests in pain exacerbated by eye movements.
- Disorders of the retinal vasculature – its symptoms include swellings of blood vessels.
- Working diagnosis: Simple anisometropia.
Differential Diagnoses
- On performing the Bruckner test using a direct ophthalmoscope in both eyes, Jessica was suffering from simple anisometropia.
- According to Tegegne et al. (2021), simple anisometropia is characterized by one eye having a refractive error. It can occur when either one of the eyes is bigger than the other, resulting in asymmetrical nearsightedness.
- An individual suffering from this condition experience blurred vision, pain, and discomfort.
Plan /Treatment
- Treatments can include corrective lenses or contact lenses.
- For contact lenses or corrective lenses to be effective, they should be prescribed differently to meet each eye’s visual needs (Bailey & Jackson, 2016).
- The patient should be educated on the importance of wearing lenses.
- The patient should maintain balance diet.
- She should exercise regularly
References
Bailey, I. L., & Jackson, A. J. (2016). Changes in the clinical measurement of visual acuity. In Journal of Physics: Conference Series (Vol. 772, No. 1, p. 012046). IOP Publishing.
Tegegne, M. M., Assem, A. S., & Merie, Y. A. (2021). Prevalence and Associated Factors of Amblyopia Among School-Age Children at Bahir Dar City, Northwest Ethiopia: A Community-Based Cross-Sectional Study. Clinical Optometry, 13, 143.