This patient has come into the office complaining of decreased vision with a bothersome glare that has increased over the past year.
Case 5
Discussion 6
This patient has come into the office complaining of decreased vision with a bothersome glare that has increased over the past year. He has also verbalized tripping and not recognizing people until they get close. The patient’s vitals are stable and therefore additional information and data should be collected. As the primary care physician, it is important to obtain information regarding how the patient’s vision has changed, and the patients wears prescription glasses and how often has the prescription been changed. If there is any headaches, nausea or vomiting associated with vision changes. The pcp should further inquire if the patient has been experiencing halos around light. Moreover, a complete medical, social and family history should also be obtained as this patient’s records have not been received by the new PCP. The PCP should know if the patient has been diagnosed with diabetes or any renal diseases. The patient should also be asked about any prolonged steroid use as these diseases and medications can lead to vision changes such as glaucoma. With that, the patient should be assessed for any smoking or alcohol use as well as any family history of eye disorders or genetic diseases. Therefore, the physician will order diagnostic and laboratory test to further rule out or confirm the patient’s diagnosis. An eye exam will be performed to assess the opacity of the lens. A fundoscopy can also be used as well as performing an Impaired red reflex test. Moreover, it is also important to perform a urinalysis to assess for ketone, lipid profile as well as a random glucose test (Furtak-Pobrotyn et al., 2018). Untreated diabetes can lead to other health conditions to develop such as glaucoma or blindness (Xie et al., 2023). In addition, cataracts, glaucoma and diabetic retinopathy are all possible differential diagnosis for this patient given his current complaints and symptoms. Therefore, it is important to perform all necessary testing to rule out or confirm these diagnosis. Furthermore, a fluorescein angiography should also be ordered to identify presence of macular degeneration, an ultrasonography and CT scanning for cataract evaluation as well as an MRI (Xie et al., 2023). Once the patient’s diagnosis is confirmed only then can treatment be discussed. Given the patients symptoms and current condition it is likely he has cataract and therefore should be referred to an ophthalmologist for cataract surgery. If the patient does not have prescription glasses, then he must be urged to obtain them while waiting to visit with ophthalmologist and have cataract surgery performed (Xie et al., 2023). Eye drops may also be ordered such as Atropine, or phenylephrine to help improve vision until cataract surgery is performed (Furtak-Pobrotyn et al., 2018). During this time the patient should be educated that these treatments do not cure the cataract and only provides minor reliefs. Therefore, only cataract surgery can correct these issues. The patient should be educated that this is an outpatient procedure, and the patient will need someone to drive him to and from the visit. The procedure should also be explained to this patient as well as what to expect before and after the procedure. The patient will be educated that redness in the eyes, itching sensation and discharge are common after cataract surgery and how to properly care for his eyes and maintain clean hand hygiene. With that, the patient should also be educated on potential complications include inflammation, bleeding, infection, drooping eyelid, dislocation of artificial lens, retinal detachment and glaucoma due to changes in pressure (Furtak-Pobrotyn et al., 2018). Therefore, the patient will further be educated to not lift anything above 15lbs, avoid washing eye, and stop smoking or drinking if he does so currently.
Reference
Xie, J., Li, W., & Han, B. (2023). The Treatment of Primary Angle-Closure Glaucoma with Cataract: A Systematic Review and Meta-Analysis of Randomized Controlled Trails. Ophthalmology & Therapy, 12(2), 675–689. https://doi.org/10.1007/s40123-022-00639-z
FURTAK-POBROTYN, J., POBROTYN, P., WITCZAK, I., RYPICZ, Ł., SUSŁO, R., JAŻDŻ-ZALESKA5, R., & DROBNIK, J. (2018). The effect of modern medical technology on the availability and cost of cataract treatment in older patients. Family Medicine & Primary Care Review, 20(3), 222–226. https://doi.org/10.5114/fmpcr.2018.78255
done
What additional subjective data are you seeking to include past medical history, social, and relevant family history?In addition to past medical history, social history, and relevant family history, it would be important to obtain further subjective data on the onset and progression of the patient’s vision loss, the specific tasks and activities that are affected by the vision loss, and any associated symptoms such as pain, redness, or discharge. Information on the patient’s occupation, hobbies, and daily routine would also be helpful in understanding the impact of the vision loss on their quality of life (Azizi et al., 2020).What additional objective data will you be assessing for?Additional objective data that would be useful in evaluating the patient’s vision loss include a comprehensive eye exam, including measurement of visual acuity, visual fields, and intraocular pressure. A slit-lamp exam and dilated fundus examination would be necessary to evaluate the structures of the eye, including the lens, retina, and optic nerve. Optical coherence tomography (OCT) and fluorescein angiography may also be useful in identifying any structural or functional abnormalities in the retina or macula.What are the differential diagnoses that you are considering?The differential diagnosis for the patient’s vision loss could include a variety of conditions, such as cataract, age-related macular degeneration, diabetic retinopathy, glaucoma, and optic neuropathy. The specific diagnosis would depend on the results of the comprehensive eye exam and other diagnostic tests.What laboratory tests will help you rule out some of the differential diagnoses?Laboratory tests that may help rule out some of the differential diagnoses could include a fasting blood glucose test to evaluate for diabetes, complete blood count to evaluate for anemia or infection, and inflammatory markers such as erythrocyte sedimentation rate or C-reactive protein to evaluate for inflammation.What radiological examinations or additional diagnostic studies would you order?Additional diagnostic studies that may be ordered include OCT, fundus photography, and fluorescein angiography to evaluate the structures of the eye and any damage or abnormalities (Agarwal et al., 2023). In some cases, additional imaging studies such as magnetic resonance imaging or computed tomography may be necessary to evaluate for optic neuropathy or other neurological conditions.What treatment and specific information about the prescription that you will give this patient?If the diagnosis is cataract, the treatment would be surgical removal of the lens with intraocular lens implantation. The patient would be prescribed eye drops to prevent infection and inflammation, as well as pain medications and other medications as needed. The patient would also receive specific instructions on postoperative care and follow-up appointments.What are the potential complications from the treatment ordered?Potential complications from cataract surgery could include infection, inflammation, bleeding, or complications related to anesthesia (Ivić, 2021). Additionally, there is a small risk of complications such as retinal detachment or intraocular lens dislocation in the months or years following surgery.What additional laboratory tests might you consider ordering?Additional laboratory tests that may be ordered include blood pressure, serum creatinine levels, and electrocardiogram to assess the patient’s overall health and suitability for surgery.What additional patient teaching may be needed?Patient education should include proper use of eye drops, postoperative care, and follow-up appointments. The patient should be advised to avoid activities such as heavy lifting, bending over, and rubbing the eye. They should also be informed about potential complications and when to seek medical attention.Will you be looking for a consult?Aconsult with an ophthalmologist would be appropriate for further evaluation and management of the patient’s condition. The ophthalmologist would be able to provide more specialized diagnostic and treatment options.ReferencesAgarwal, A., Pichi, F., Invernizzi, A., Grewal, D. S., Singh, R. B., & Upadhyay, A. (2023). Stepwise approach for fundus imaging in the diagnosis and management of posterior uveitis. Survey of Ophthalmology.Azizi, A., Achak, D., Aboudi, K., Saad, E., Nejjari, C., Nouira, Y., &Marfak, A. (2020). Health-related quality of life and behavior-related lifestyle changes due to the COVID-19 home confinement: Dataset from a Moroccan sample. Data in brief, 32, 106239.Ivić, L. (2021). Early and late complications of cataract surgery (Doctoral dissertation, University of Zagreb. School of Medicine).Edited by Posada Hernandez, FlorSahily on Apr 20 at 1:22pm ReplyReply to Comment
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