Patient History and Physical Examination

Patient Name: Jessica

Chief Complaint: losing vision in her left eye. It began this morning when she woke up, and it is progressing. It is painful for her to look around.

History of present illness: The patient denies any trauma or injury. Losing vision started in the morning when she woke up and has worsened progressively over the past few hours. The patient had some vision blurring a month ago and thinks that it could have been connected with getting overheated since it improved when she was able to get in a cool environment. There is some pain when she tries to move her eye, but no pain when she relaxes. The patient is also unable to determine colors. She denies redness, tearing, or exposure to any chemicals.

Past Medical History: Chickenpox at the age of ten and a tonsillectomy/adenoidectomy at the age of eleven.

Family History: The patient’s mother has hypertension, and her father has coronary artery disease (he had a stent placed at age 67).

Personal and Social History

The patient has been socially active all of her life. She completed a bachelor’s degree in mathematics and a master’s degree in education. She quit smoking 10 years ago. She drinks an occasional wine cooler, and she denies illicit drug use.

Review of Systems

General: Patient is alert. She appears anxious.

Skin: There is no presence of any rash or itching. There is no abnormal hair distribution.

Head and Neck: There is no story of neck pain, headache, or stiffness.

Eyes: sudden decrease of vision in the left eye. The patient denies any trauma or injury. Losing vision started in the morning when she woke up and has worsened progressively over the past few hours. The patient had some vision blurring a month ago and thinks that it could have been connected with getting overheated since it improved when she was able to get in a cool environment. There is some pain when she tries to move her eye, but no pain when she relaxes. The patient is also unable to determine colors. She denies redness, tearing, or exposure to any chemicals. Nothing has made it better or worse.

Ears, Nose, Throat, and Mouth: There is no presence of loss of hearing, ear pain, or sinus congestion. There is no pain in the mouth or cough.

Lymphatic System: The patient does not have any node enlargement or tenderness.

Chest and Lungs: There is no shortness of breath, chest pain, or cough.

Breasts: There is no pain, tenderness, or discharge.

Heart and Blood Vessels: No edema, no palpitation.

Gastrointestinal and Endocrine Systems: The patient does not have any abdominal pain, vomiting, polyphagia or polydipsia, or temperature intolerance.

Genitourinary System: The patient does not have pain with urination. G=4, T=4, P=0, A=0, L=4, they were vaginal deliveries.

Musculoskeletal System: There is no muscular pain, restriction of movements, or joint stiffness.

Nervous System: There is no weakness or change in sensations.

Physical Examination

General: The patient appears comfortable, cooperative with the interviewer and the examination procedures. Vital signs are BP 135/85 mm Hg; HR 64bpm and regular, RR 16 per minute, T: 98.5F. The patient is not currently under the influence of alcohol or other drugs. Jessica ambulates without difficulty, articulates clearly, and is not in distress.

Mental Status: Patient is alert, oriented in time, place, and person

Skin: No change in color or pigmentation. No rashes or lesions. Hair with normal distribution and texture.