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Case Study
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Nursing Case Study: History And Physical Examination (Case Study Sample)


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.
Make a whole history and physical examination in a comprehensive manner with all its elements included: CC, HPI, PMH, FH, SH, MEDICATIONS, ALLERGIES, ROS PER APPARATUS OR SYSTEMNS, HEAD TO TOE PHYSIACL EXAMINATION PER SYSTEMS ( write your presentation in H&P format no paragraph format).
Based on this information, what is your presumptive nursing diagnosis? All nursing diagnosis that apply to the case written in NANDA format related to ... and evidence by...., NO MEDICAL DIAGNOSIS.
Teaching plan and nursing care plan per each nursing diagnosis on this case.
1- All written assignment and documentations must be in APA 6th edition format.
2- Double spaces, minimum 4 pages long , minimum 3 up to date bibliography. (UP to date means last 3 years.), Note: you can use your test book as bibliography too, bibliography have to be written in APA format.


History and Physical Examination
History and Physical Examination
Chief Complaint: Jessica, a female-aged 32 years old, presents to the emergency room accompanied by her friend with the chief complaint being sudden decline of vision her left eye.
Present Illness History
Jessica claims that the decline of vision in the left eye began early in the morning after she got up. Since then, the problem has gradually deteriorated over the last few hours. The patient reports that she had not had any injury or trauma and chemical exposure. Additionally, she claimed that a month ago, she experienced some blurring of her vision though she thought that this might have resulted from being overheated given that it improved after going in a well air-conditioned surrounding. Currently, Jessica claims that she feels some pain when she attempts to move the affected eye, though the pain resolves when she rests. In addition, she is not also able to differentiate colors. According to her, nothing has enhanced or made her condition.
Medical History
Jessica reports that she is usually healthy. At the age of 10, she reports that she suffered from chickenpox. She reports that she has never been hospitalized.
Surgical History
At the age of 11, she had an adenoidectomy/tonsillectomy. No history of caesarian section was reported
Currently, she reports that she has no medical problems and thus, she is not under any medications.
The patient does not report any allergies
Family History
She reports that her father has a coronary artery disease.
She also reports that her mother suffers from hypertension
Reproductive History
The patient has four children, all delivered through spontaneous vaginal delivery
Drug Abuse History
The patient has a history of tobacco smoking though she quit 10 years ago. Before quitting, she reports that she used to take two cigarettes packs every day for a period of around five years. She also takes wine cooler seldom. Jessica denies any history of illicit drug use
Psychosocial History
The patient is a mathematics teacher. She reports that she finished her degree in mathematics as well as a master’s degree in education.
Review of systems
HEET: she denies headaches, alterations in hearing, sinus or nasal congestion, sore throat and stiffness or pain in the neck.
General: she denies fever, night sweats, chills, and weight loss
Genitourinary: she denies dysuria, hematuria, polyuria, and vaginal discharge
Musculoskeletal: All muscles have a normal bulk as well as tone
Cardiovascular: Denies chest pains, peripheral edema, shortness of breath, palpations, and cough
Gastrointestinal: No complaints of polydipsia and polyphagia. She denies adnominal pain, constipation, and diarrhea
Physical Examination
Vitals: Blood pressure 135/85 mm Hg; HR 64bpm; RR 16/min; T 98.5F
General: The patient seems alert. She appears to be anxious
Eyes: The Visual of the left eye and right eye is 20/200 and 20/20 respectively; Sclera and conjunctive normal; Unable to evaluate visual fields in the left eye; however, the visual field of the other eye is normal. The response of the pupil is reduced in the affected eye and brisk for the right eye. The left eye’s optic disk seems distended.
Musculoskeletal: All joints have full range motions in all joints; no deformity or swelling noted; all muscles have a normal bulk as well as tone.
Neurological: Cranial nerves I-XII are intact, negative Romberg; motor along with sensory examination of the lower and upper extremities seems normal; intact to temperature and vibration; reflexes appear normal as well as symmetrical in all extremities ( reflexes 2+ as well as symmetric in triceps, biceps, patellar, brachioradialis as well as Achiles tendons; no Babinski noted.
Mental status: The patient is fully oriented to person, time, and place (oriented x 3)
Nursing Diagnosis
Problem-Focused Diagnosis
Disturbed visual perception alteration as evidenced by the sudden decrease in vision for the left eye (Brown, 2017). Loss of visual vision loss as evidenced by the visual acuity of 20/200 in the patients left eye and the inability to differentiate different colors. Optic disc edema as evidenced by the swollen optic disc in the left eye (Lorach et al., 2015). Anxiety as evidenced by the nervousness of the patient during anxiety. High blood pressure as evidenced by the patient's blood pressure of 135/85. Even though this level of blood pressure may be normal, there is a history of hypertension within the patient’s family and coronary artery disease, which is also associated with hypertension (Goel et al., 2015). Acute pain as evidenced by pain as the patient tries to move her left eye.
Risk Diagnosis
The risk for injury as evidenced by the reduced vision in the patients left eye. When the vision of one eye is impaired, a person is usually a higher risk of misjudging activities and thus can cause unintentional harm to themselves (Lorach et al., 2015). The risk for blindness as evidenced by the reduced vision, pain, and inability to differentiate colors in the patient's left eye. The risk for hypertension as evidenced by a history the condition within the patient's family. The risk for physical immobility due to the reduced vision of the left eye (Lorach et al., 2015). The risk for atherosclerosis as evidenced by the family history of coronary heart disease (Goff et al., 2014). Another possible risk is that of acute confusion as shown by the patient's pain in the left eye and anxiety. The patient is also at the risk of papilledema as evidenced by the swelling of the optical nerve. Lastly, the patient is at the risk of chronic pain as evidenced by the acute pain in the left eye.
Health Promotion
The patient shows readiness for enhanced vision as well as the desire for a better as shown by her cooperation with the inquiries of the nurse. Additionally, the patient demonstrates readiness for improved comfort as evidenced by her desire to seek clinical attention due to her condition.
Nursing Care Plan and Teaching Plan
The most appropriate nursing care plan in the patient’s case should be aimed at preventing further visual deterioration, promoting adaptation to ch...
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