Nursing: Case Study, Outline Example

Demographic Data

Name: Mr. G

Gender: Male

Age:  55 years old

Race: African American

Religion: Islam

Occupation: Accountant

Initial Presentation

Chief Complaint

• The patient has come into the eye hospital complaining about continuously experiencing blurry vision. Apart from the blurry vision, the patient complains about having difficulty focusing on objects at all distances. He has had to adjust his reading style as he finds it difficult to make out the letters in books and newspapers.

History of Presenting Illness

• The 55-year-old male patient presents with poor vision in both eyes but with a significantly poorer vision of the right eye.
• The patient first noted the changes in their vision eight months ago and their vision was rated poor 25/150. They noted a progressive loss in vision that was not associated with any pain.
• She noted that the right eye experienced worse vision loss compared to the left eye.
• She denies any form of double vision in either eye.
• She also denies any transient visual obscurations.

Past Medical history

• Hypertension
• Type II Diabetes

Medications

• Carvedilol
• Hydrochlorthiazide (HCTZ)
• Furosemide
• Aspirin
• Novolog

Allergies

• No known allergies

Family History

• Three out of five of the patient’s relatives report having myopia.
• Two out of five of the patient’s relatives have had eye surgery, the most common being a cataract-removal surgery.

Social and Personal History

• The patient reports occasional alcohol use but does not report any tobacco consumption.
• The patient’s occupation exposes them to long hours looking at digital screens.

Review of Systems

• A negative result of the full review of systems except for what is made available in the patient’s history of the present illness.

Ocular Examination

Visual Acuity with Correction (Snellen)

• Right eye (OD): 25/150.
• Left eye (OS): 40/150.

Manifest Refraction

• OD: -1.25 sphere (myopic shift from the previous refraction) 17/25.
• OS: -1.25 sphere (myopic shift from the previous refraction) 19/25.

Ocular Motility/Alignment

• Full both eyes OU.

Intraocular Pressure (IOP)

• OD: 20 mmHg.
• OS: 17 mmHg.

Pupils

• OD: 4mm in dark to 2mm in light, no relative afferent pupillary defect (RAPD).
• OS: 4mm in dark, 2mm in light, no RAPD.

Confrontation Visual Fields

• Full OU to counting fingers

Slit Lamp Exam

• Lids/lashes: Normal OU.
• Conjunctiva/sclera: Clear and quiet OU.
• Cornea: Corneal graft clear and compact OD. Normal OS.
• Anterior chamber: Deep and quiet OU.
• Iris: Normal architecture OU.
• Lens: PCIOL in the capsular bag with a distended posterior capsule filled with turbid fluid and peripheral white lens material OD. Unremarkable OS.

Dilated Fundus Examination (DFE)

• OD: No view secondary to the dense cataract
• OS: Red reflex present, but very hazy view secondary to cataract

Echography

• B scan OU: No evidence of retinal detachment or a mass lesion
• Immersion axial eye length: 24.93mm OD, 24.72mm OS.

References

Deshmukh, S., Bhattacharjee, H. & Gupta, K., 2019. “Triangle sign” in Morgagnian cataract. Indian journal of ophthalmology, 67(1), p. 137.

Eadie, B. J., Heathcote, G. & Gupta, R. R., 2019. Acute Phacolytic Glaucoma and Morgagnian Cataract. JAMA ophthalmology, 137(4), pp. e184495-e184495.

Gupta, G., Jain, A. K. & Malhotra, C., 2020. Morgagnian cataract. QJM: An International Journal of Medicine, 113(4), p. 291.

Hollmann, A. K. et al., 2017. Morgagnian cataract resulting from a naturally occurring nonsense mutation elucidates a role of CPAMD8 in mammalian lens development. PloS one, 12(7), p. e0180665.

Hua, X. et al., 2019. Intraocular lens implantation performed first to protect the posterior capsule in Morgagnian cataracts during phacoemulsification. International journal of ophthalmology, 12(7), p. 1215–1218.

Mora, P. et al., 2020. A case of morgagnian cataract mimicking an iris tumor. American journal of ophthalmology case reports, Volume 18, p. 100685.