additional objective data to assess

A 79-year-old male remarks on his first visit that he has noticed a gradual decrease in vision in both his eyes since last year. His old medical record has not yet arrived at your office. He states that since he moved from Florida a year ago, he has not had an eye examination and does not yet know an ophthalmologist. He is having difficulty carrying on his activities of daily living that involve his sight. He states that he cannot recognize people at some distance until they come quite close and he is often frightened by his perception of strangers speaking to him. Watching television and reading are becoming increasingly difficult for him. He states that glare is a problem and notes that a few times he almost tripped over something on the floor. He still drives his car in the local community. He asks if you think he may have a cataract. He says his wife had two cataracts in the past and he remembers her complaining of vision problems which have now resolved.

Vital Signs: BP 128/84; HR 82; RR 18; BMI 24.

Chief Complaint: Decrease in my vision; glare is very bothersome!

Discuss the following:

1) What additional subjective data are you seeking to include past medical history, social, and relevant family history?
2) What additional objective data will you be assessing for?
3) What are the differential diagnoses that you are considering?
4) What laboratory tests will help you rule out some of the differential diagnoses?
5) What radiological examinations or additional diagnostic studies would you order?
6) What treatment and specific information about the prescription that you will give this patient?
7) What are the potential complications from the treatment ordered?
8) What additional laboratory tests might you consider ordering?
9) What additional patient teaching may be needed?
10) Will you be looking for a consult?

 

Submission Instructions:

• Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources. Your initial post is worth 8 points.

1. Additional subjective data to gather would include:

• Detailed information about the gradual decrease in vision, such as when it started, if it has worsened over time, and any associated symptoms like pain or redness.
• History of any previous eye conditions or surgeries, including the specific details of his wife’s cataract surgeries.
• Medications and allergies, as certain medications can affect vision.
• Social history, including occupation (especially if it involves prolonged exposure to sunlight or other environmental factors that may contribute to vision problems), smoking history, and alcohol consumption.
• Family history of eye diseases, such as glaucoma, macular degeneration, or retinal detachment.

2. Additional objective data to assess for would include:

• Visual acuity testing using a Snellen chart or other appropriate methods.
• Examination of the external structures of the eye, including eyelids, conjunctiva, and cornea.
• Measurement of intraocular pressure to screen for glaucoma.
• Pupillary examination and assessment of the reaction to light.
• Evaluation of the lens for opacity or cloudiness, which may indicate cataracts.
• Assessment of the fundus (retina) using ophthalmoscopy or other imaging techniques to evaluate the health of the optic nerve and retina.

3. The differential diagnoses that should be considered include:

• Cataracts: Given the patient’s age, gradual decrease in vision, and a family history of cataracts in his wife, this is a likely possibility.
• Age-related macular degeneration (AMD): This condition can cause central vision loss and may be associated with glare and difficulty recognizing faces.
• Glaucoma: Increased intraocular pressure can lead to gradual vision loss, especially in the peripheral vision.
• Diabetic retinopathy: If the patient has a history of diabetes, this condition should be considered, as it can cause vision changes.
• Other causes of vision loss, such as retinal detachment, optic neuropathy, or ocular tumors.

4. Laboratory tests that may help rule out some differential diagnoses include:

• Blood glucose levels and HbA1c to assess for diabetes or poorly controlled blood sugar.
• Complete blood count (CBC) to evaluate for signs of infection or inflammation.
• Erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) to assess for systemic inflammation.
• Serum electrolytes and renal function tests to ensure the patient can undergo certain diagnostic procedures or treatments if needed.

5. Radiological examinations or additional diagnostic studies that may be ordered include:

• Optical coherence tomography (OCT): This non-invasive imaging technique provides detailed cross-sectional images of the retina, helping to evaluate the macula and optic nerve.
• Visual field testing: This test assesses the peripheral vision and can aid in the diagnosis of conditions like glaucoma.
• Ultrasound or MRI of the eye: These imaging modalities may be useful in assessing the structures of the eye if there is suspicion of retinal detachment or ocular tumors.

6. The treatment for cataracts, if confirmed, is surgical removal of the cloudy lens. However, before discussing treatment options, further examination and diagnostic tests are necessary to confirm the diagnosis of cataracts and assess the overall health of the patient’s eyes.
7. Potential complications from cataract surgery include infection, bleeding, swelling, or retinal detachment. It is important to inform the patient about the potential risks and benefits of the surgery, as well as the post-operative care instructions to minimize complications.
8. Additional laboratory tests that might be considered include:

• HbA1c and fasting blood glucose levels if diabetes is suspected or the patient has a history of diabetes.
• Lipid profile to assess cardiovascular risk factors that may contribute to eye conditions like AMD.

9. Additional patient teaching may be needed regarding:

• The importance of regular eye examinations and seeking timely care for any changes in vision.
• Strategies to minimize glare, such as using sunglasses, adjusting lighting, or using anti-glare filters for screens.
• Safety precautions, particularly if the patient is still driving, as impaired vision can pose a risk to themselves and others.

10. Depending on the findings and diagnosis, a consult with an ophthalmologist may be necessary for further evaluation and specialized care.