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Comprehensive Patient Assessment
Chief Complain (CC)
“A sudden decrease of vision in the left eye”
History of Present Illness (HPI)
The 32-year old patient first experienced blurred vision one month ago. The vision improved when she moved from an overheated environment to a cool air-conditioned environment. The current problem started in the morning with the symptoms worsening progressively over the past few hours. The patient feels some pain when she tries to move the left eye. The pain abates when she rests the eyes. She cannot distinguish the different colors. The patient denies any trauma or injury. She denies any tearing, redness or exposure to chemicals. None of the tried interventions have improved or worsened the symptoms.
Past Medical History (PMI)
The patient suffered chickenpox at the age of 10 and had a tonsillectomy at the age of 11. She has not had any major medical problems in adulthood and has not needed hospitalization for whatever reason. The patient has delivered all her four children via the normal vaginal delivery. She has not undergone any surgical procedures in adulthood. The patient has no known allergies to particular medications, foods and environmental allergens. She has not been taking any medications. She has not tried complementary treatments such as acupuncture.
Family History (FH)
The patient’s father and mother are alive. The father has a coronary heart disease and underwent a stent placement procedure at the age of 67. Her mother has hypertension. There is no known history of diabetes, cancer, arthritis, and kidney disease in the family.
Social History (SH)
Jessica has a bachelor’s degree in mathematics and a master’s degree in education. She is a math teacher. She has been smoking two packs of cigarette daily for five years. She quit 10 years ago.
The patient drinks wine cooler occasionally. She denies the use of illicit drugs.
Review of Systems (ROS)
- General – The patient has not had any major medical issue in the past, her weight is normal, no complaints of fever, fatigue, chills, night sweats, recent weight loss
- Head, eyes, ears, nose and throat (HEENT) – No complaints of headache, hearing loss, sore throat, nasal or sinus congestion, mouth sores or ulcers.
- Neck – Easily moveable, no complaints of pain
- Respiratory – No complaints of cough, shortness of breath, history of asthma, tuberculosis, pneumonia, pulmonary embolism
Cardiovascular – No complaints of che…………….
