Right eye pain (1)

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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? i e ; onset, location, quality, in tensity, and exacerbating or alleviating factors. I s 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 h istory

12. I nspect the external eye, eyelids, lacrimal ducts, sclera, conjuctiva , cornea, and iris for color, drainage, swelling or ulcerations P alpate 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 Objective Data The Eyes Have It

13. Possible Hypotheses, Actions, Recommendations, & Solutions Differential Diagnoses : Corneal injury from abrasion or embedded foreign body Iritis Keratitis Entropion

14. Corneal Injury Abrasion or Foreign Body Treatment/Plan Removal of foreign body if superficial by flushing or use of cotton swab Referral to skilled practitioner for 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 Diagnosed with eye exam

15. Iritis Treatment/Plan Referral to an opthamologist if suspected Cycloplegic drops to dilate pupil M ild analgesics S teroid eye drops I f severe, steroid injections Treat the underlying cause if related to systemic disease * *glaucoma test performed to measure intraocular pressure if iritis is suspected Diagnosed by slit lamp exam

16. Keratitis Treatment/Plan Topical, PO, or IV a ntibacterial, antifungal or antiviral therapy (depending on cause) Artificial tears Steroid drops Referral to specialist for s urgical 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 Diagnosed by vision exam with a slit lamp

17. Entropion Treatment/Plan Artificial tears/lubricants Skin tape Botox Teach eye hygiene/care Referral to surgeon; eventually will need corrective surgery Diagnosed by physical examination of eyes and eyelids

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.