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Hypnotherapy Case Studies

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Subjective:
Chief Complaint: N.G., a 33 year old Hispanic female who appears reliable presents today with complaints of “something is in my left eye”.
HPI: This patient claims that a piece of plastic off of a milk crate broke and flew directly into her left eye when she was attempting to set it down yesterday evening. She claims that the pain started immediately and was a “10/10”. The pain has only improved slightly overnight to a “8/10” this morning. She describes this pain as a sharp, burning and stabbing type of pain. She has obtained some relief from rinsing her left eye out repeatedly and then applying cool compresses and ice packs. She claims that opening her eye makes the pain worse and causes her “eye to water”. She denies any radiation of …show more content…

Plan of Care: No laboratory work ordered at this time. Patient prescribed Tobramycin ophthalmic ointment 1/4 to 1/2 inch ribbon to lower conjunctiva every four hours while awake (Medscape, 2014). Patient instructed to keep eye clean using a dilute baby shampoo solution twice daily. The patient is instructed to seek immediate medical intervention for visual changes, fever greater than 100.0, or increasing ocular pain. Return for follow-up appointment in two days (Goolsby & Grubs, 2011). Continue current medication regime as previously prescribed.
Evaluation: I was provided the opportunity to observe and participate in fluorescein staining of the eye to assess for scleral abrasions. Bailey, Buttaro, Sandberg-Cook, and Trybulski (2013) claim that the degree of injury is determined by the size of the object and the amount of mechanical energy the foreign object obtained prior to reaching the surface of the eye. This patient was in severe pain, yet received only a minor trauma to conjunctival aspect of the upper eyelid. It is imperative for her to keep her follow-up appointment as infection and ulcers are common after ocular injuries (Bailey et al., 2013).

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