So in this case, the patient presents with complaints of the recent loss of vision.

Q-1

So in this case, the patient presents with complaints of the recent loss of vision. Upon discussing this with the patient I discovered that the loss was recent but he did not lose total vision. The lack of total loss of vision helped to rule out retinal detachment, which is a medical emergency (Begaj et al., 2020). Continuing on with the conversation, I discovered that the patient has a long history of diabetes with medication non-compliance. The patient gave a number of reasons as to why, each reason was different depending on the patient’s stage of life, but was high when he had his appendix out when he was in his thirties. This told me that the patient was unable to manage his diabetes for a long time. Having diabetes leads to a whole plethora of problems, but when combining this information with the patient’s chief complaint of vision disturbance, it helped narrow the differential diagnosis down to diabetes-related ocular diseases (Gardner & Sundstrom, 2017). At this point, my differential diagnosis was Diabetic Retinopathy, Posterior Vitreous Detachment, Glaucoma, Macular Degeneration, Retinal Detachment (Gardner & Sundstrom, 2017). I felt I had to include retinal detachment in my differentials because the risk of missing it outweighs the risk of assessing for it. 

Further assessment using an ophthalmoscope revealed that the patient had multiple areas of microaneurysms, hemorrhaging, and AV nicking. Combining this with the patient’s report of the recent decrease in visual acuity and intermittent flashes of light and floaters strengthened the diagnoses of Diabetic Retinopathy and Posterior Vitreous Detachment (Gardner & Sundstrom, 2017). Thinking about the management process of these two diseases I realized that there is no way to reverse the disease process, but to only slow down or halt the progression (Gardner & Sundstrom, 2017). With Posterior Vitreous Detachment, there is a strong possibility that the disease process will reverse on its own, but the patient will have a substantially high risk of retinal detachment over the next three months (Gardner & Sundstrom, 2017). He would definitely need the ophthalmology appointments the most, and if forced to pick one healthcare provider, this would be the one I would recommend to see frequently until the risks have subsided. The appropriate treatment for this patient at this point was now dependent on the patient’s problem list and getting the items addressed. 

The biggest problem that the patient felt was actually his financial situation first, access to healthcare second, and finally his vision disturbance third. The patient had stated multiple times that he was unable to access healthcare appropriately due to financial concerns where the healthcare visits were too expensive and he was unable to utilize his current insurance effectively and was unable to get “better insurance like my wife’s disability insurance”. The first step in managing this patient’s issues is consulting Case Management or Social Workers to help this patient and see if he qualifies for better insurance like Medicare or Medicaid. At the same time to bridge the application wait times, we could attempt to enroll this patient into other state assistance programs, and Walmart’s non-insurance Insulin program. If we could enroll him into these programs we could see if he would qualify for an endocrine consult to better manage his insulin schedule and where he is at in his disease process and ophthalmology consult to see where he is at in his disease process. 

Hopefully, with the combination of state-assistance programs and government insurance, we will be able to get this patient the ability to access healthcare that he needs and to be able to appropriately treat this patient effectively. 

One issue that I realized I had with this scenario is that I did not include diagnoses of diabetes type II, glucose intolerance, and cataracts in my differential list. I realize now that every time you see a patient, you need to include all diagnoses especially if they relate to the current disease process. 

References:

Begaj, T., Marmalidou, A., Papakostas, T. D., Diaz, J. D., Kim, L. A., Wu, D. M., & Miller, J. B. (2020). Outcomes of primary rhegmatogenous retinal detachment repair with extensive scleral-depressed vitreous removal and dynamic examination. PloS One15(9), e0239138. https://doi-org.lopes.idm.oclc.org/10.1371/journal.pone.0239138

Gardner, T. W., & Sundstrom, J. M. (2017). A proposal for early and personalized treatment of diabetic retinopathy based on clinical pathophysiology and molecular phenotyping. Vision Research139, 153–160. https://doi-org.lopes.idm.oclc.org/10.1016/j.visres.2017.03.006

Q-2

Chronic Rhinosinusitis (CRS) is a prevalent medical disorder that leads to significant patient morbidity in quality of life and decreased overall productivity. CRS is a group of disorders characterized by inflammation of the mucosa of the nose and paranasal sinuses that lasts for more than 12 weeks (Nath, James, & Suresh, 2017).

Before focusing on the patient’s education for CRS management, changing antibiotics is warranted as the previous antibiotic of choice, Azithromycin, is no longer recommended due to a high resistance rate. The risk of resistance should be properly evaluated prior to initiating or changing antibiotic treatment. Antibiotic with beta-lactam coverage is a more prudent option due to the failure of prior therapy. Additionally, if the patient achieved only a partial resolution of the symptoms, the clinician should consider additional 10-14 more days of antibiotic treatment combined with adjunct topical intranasal steroid and decongestant (Riviere, 2018, p. 201).

The goals of the therapy include treatment of colonizing microorganism if present, reduction of mucosal edema and inflammation, maintenance of adequate sinus ventilation and drainage, and reduction in numbers of acute exacerbations; thus, patient education should focus on providing guidance on non-pharmacologic management and pharmacologic management to ease the debilitating effect of CRS. According to Riviere (2018), patient education should include avoiding environmental irritants/ smoking cessation, which promotes swelling in the mucous membrane and cause retention of sinus exudate, appropriate control of allergic rhinitis, increasing fluid intake, sleeping with the head of the bed elevated to help in the drainage of fluid, and education about the disease and other treatment options (i.e., surgery). Furthermore, the use of saline irrigation can also help reduce postnasal discharges, remove secretions, and rinse away allergens and irritants. Patient education should focus on the care of irrigation bottles to avoid contamination.

References

Nath, S. V., James, S., & Suresh, N. (2017). A prospective study of clinical profile of chronic rhinosinusitis in a tertiary care center. Journal of Evolution of Medical and Dental Sciences, 16, 1268. https://doi-org.lopes.idm.oclc.org/10.14260/jemds/2017/276

Riviere, S.L. (2018). ENT disorders: Sinusitis/Rhinosinusitis. In A. Hollier (Ed.). Clinical Guidelines in Primary Care (3rd ed., pp. 167-208). Lafayette, LA: Advanced Practice Education Associates, Inc.

Q-3

Mr. Burne is a 47-year-old male who has a chief complaint of increasing visual loss that has been going on for a couple of weeks and has gotten worse these last few days. He reports when it first started, he saw light flashes and floaters for a day or so, and then his vision got worse. He reports he sees better during the day, but not very good during the night, and worsening of his vision has been making it hard to read including street signs as walking is his mainstay of transportation. It has been affecting his daily life of getting around and taking care of his wife as she depends on him.

Possible differential diagnoses include retinal detachment, retinopathy, and open-angle glaucoma. During the assessment, the patient’s eyes were symmetric in size, shape, color, and position. PERRLA, corneas are clear, the conjunctiva is clear, moist, and without discharge. This ruled out for infection. Disc margins are sharp and a small visible cup is noted and the cup to disc ratio is about 1/3, which ruled out papilledema. Papilledema indicates increased intracranial pressure, in which findings would include engorged retinal veins, hyperemic and swollen optic disc, and loss of the optic cup (Perry, 2020). I did not rule out retinal detachment, as the patient reported light flashes and floaters initially, which then his vision has gotten worse. The increase in the visual loss within the last few days is questionable. Retinal detachment is a serious eye disease with the potential risk of blindness. If not fully detached and instead a tear is present, patients may see sudden flashing lights and/or floaters, blurry vision, reduced peripheral vision, and curtain-like shadow over the visual field (Akhlaghi et al., 2020).

The patient has hypertension (150/90mm Hg) and has the following labs of fasting blood glucose of 265 and HbA1C of 8.5%. The patient reports financial issues and has difficulty affording his medications for his diabetes, as well as, routine check-ups; therefore, his health is not well-managed. The ophthalmoscopic exam showed minimal tapering, AV nicking, and hemorrhages b/l which is typically due to hypertension and diabetes mellitus. Retinopathy is any damage to the retina of the eyes, which may cause vision impairment; thus, the most common microvascular complication of diabetes is diabetic retinopathy and is the leading cause of blindness (Mustafi et al., 2020). The findings of the ophthalmoscopic exam and his increased vision loss give significant evidence of diabetic retinopathy.

The patient reports impaired vision at night with no pain, which are some assessment findings of open-angle glaucoma. Other assessment findings may include loss of peripheral vision, b/l intraocular pressure, headaches, notching of the optic cup, and, in later stages, halos around light (Perry, 2020). Additionally, risk factors of open-angle glaucoma include diabetes and hypertension.

It is important to have basic knowledge of the pathophysiology, signs and symptoms, and disease process of common conditions/diseases to list differential diagnoses. In this scenario, I had to look up certain assessment findings to list my differentials.

References

Akhlaghi, M., Zarei, M., Ziaei, M., & Pourazizi, M. (2020). Sensitivity, specificity, and accuracy of color doppler ultrasonography for diagnosis of retinal detachment. Journal of Ophthalmic & Vision Research, 15(2), 166-171. https://doi.org/10.18502/jovr.v15i2.6733

Mustafi, D., Saraf, S. S., Shang, Q., & Olmos de Koo, L. C. (2020). New developments in angiography for the diagnosis and management of diabetic retinopathy. Diabetes Research and Clinical Practice, 167. https://doi.org/10.1016/j.diabres.2020.108361

Perry, M. (2020). Eye disease in older adults: Risk factors and treatments. Journal of Community Nursing, 34(3), 60–66. https://search-ebscohost-com.lopes.idm.oclc.org/login.aspx?direct=true&db=ccm&AN=143663240&site=eds-live&scope=site

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