NR 511 Week 3 Case Study Discussion: Part One
A 19-year-old male freshman college student presents to the student health center today with
complaints of bilateral eye discomfort. Upon further questioning you discover the following
subjective information regarding the chief complaint.
History of Present Illness
Onset 2-3 days ago
Location Both eyes
Duration Constant
Both eyes feel "gritty" with mild to moderate amount of discomfort. Further
Characteristics
describes the gritty sensation "like sand caught in your eye"
Aggravating
None identified
factors
Relieving
None identified
factors
Tried OTC visine drops once yesterday which temporarily improved the redness
but the gritty sensation, tearing and itching remained.
Treatments
Severity Level of discomfort is 2/10 on pain scale
Review of Systems (ROS)
Denies fever, chills, or recent illnesses
Constitutional
Denies contact lenses or glasses, has never experienced these symptoms
previously. Last eye exam was "a few years ago". Denies eye injury, trauma,
Eyes
visual changes or dryness. Denies crusting of lids or mucoid or purulent
drainage. Bilateral symptoms of +redness, +itching, +tearing + FB sensation.
Ears -otalgia, -otorrhea
+occasional runny nose with intermittent nasal congestion, denies sneezing.
History of seasonal nasal allergies which is aggravated in the spring but is well
Nose
controlled on loratadine and fluticasone nasal spray taken during peak season
(he is not taking either right now).
Throat Denies ST and redness
Neck Denies lymph node tenderness or swelling
Chest Denies cough, SOB and wheezing
Heart Denies chest pain
History
Medication Loratadine 10mg daily and fluticasone nasal spray daily (only takes during the
s spring months when nasal allergies flare)
PMH Seasonal allergic rhinitis with springtime triggers
PSH None
Allergies None
, Freshman student at the University of Awesome located in central Illinois. Home is
Social
in Phoenix.
Habits Denies cigarettes +recreational marijuana use +drinks 3-6 beers per weekend
FH Adopted, does not know biological parents history
Physical exam reveals the following.
Physical Exam
Constitutional Young adult male in NAD, alert and oriented, cooperative
VS Temp-97.9, P-68, R-16, BP 120/75, Height 6'0, Weight 195 pounds
Head Normocephalic
Visual Acuity 20/20 (uncorrected) OU. PERRL with white sclera bilaterally.
Slight light sensitivity noted bilaterally. No crusting, lesions or masses on lids
noted. Bilateral conjunctiva with diffuse redness and tearing but no mucoid or
purulent drainage noted. No visible FBs under lids or on cornea to gross
Eyes examination.
Fundiscopic examination: Discs flat with sharp margins. Vessels present in all
quadrants without crossing defects. Retinal background has even color, no
hemorrhages noted. Macula has even color.
Tympanic membranes gray and intact with light reflex noted. Pinna and tragus
Ears
nontender.
Nares patent. Nasal turbinates are pale and boggy with mild to moderate
Nose
swelling. Nasal drainage is clear.
Oropharynx moist, no lesions or exudate. Tonsils ¼ bilaterally. Teeth in good
Throat
repair, no cavities noted.
Neck supple. No lymphadenopathy. Thyroid midline, small and firm without
Neck
palpable masses.
Heart S1 and S2 noted, no murmurs, noted. Lungs clear to auscultation
Cardiopulmonary
bilaterally. Respirations unlabored.
1. Briefly and concisely summarize the history and physical (H&P) findings as if you were
presenting it to your preceptor using the pertinent facts from the case. Use shorthand
where possible and approved medical abbreviations. Avoid redundancy and irrelevant
information.
2. Provide a differential diagnosis (minimum of 3) which might explain the patient's chief
complaint along with a brief statement of pathophysiology for each.
3. Analyze the differential by using the pertinent findings from the history and physical to
argue for or against a diagnosis.
4. Rank the differential in order of most likely to least likely.
5. Identify any additional tests and/or procedures that you feel is necessary or needed to
help you narrow your differential. All testing decisions must be supported with an
evidence-based medicine (EBM) argument as to why it is necessary or pertinent in this
case. If no testing is indicated or needed, you must also support this decision with EBM
evidence.
A 19-year-old male freshman college student presents to the student health center today with
complaints of bilateral eye discomfort. Upon further questioning you discover the following
subjective information regarding the chief complaint.
History of Present Illness
Onset 2-3 days ago
Location Both eyes
Duration Constant
Both eyes feel "gritty" with mild to moderate amount of discomfort. Further
Characteristics
describes the gritty sensation "like sand caught in your eye"
Aggravating
None identified
factors
Relieving
None identified
factors
Tried OTC visine drops once yesterday which temporarily improved the redness
but the gritty sensation, tearing and itching remained.
Treatments
Severity Level of discomfort is 2/10 on pain scale
Review of Systems (ROS)
Denies fever, chills, or recent illnesses
Constitutional
Denies contact lenses or glasses, has never experienced these symptoms
previously. Last eye exam was "a few years ago". Denies eye injury, trauma,
Eyes
visual changes or dryness. Denies crusting of lids or mucoid or purulent
drainage. Bilateral symptoms of +redness, +itching, +tearing + FB sensation.
Ears -otalgia, -otorrhea
+occasional runny nose with intermittent nasal congestion, denies sneezing.
History of seasonal nasal allergies which is aggravated in the spring but is well
Nose
controlled on loratadine and fluticasone nasal spray taken during peak season
(he is not taking either right now).
Throat Denies ST and redness
Neck Denies lymph node tenderness or swelling
Chest Denies cough, SOB and wheezing
Heart Denies chest pain
History
Medication Loratadine 10mg daily and fluticasone nasal spray daily (only takes during the
s spring months when nasal allergies flare)
PMH Seasonal allergic rhinitis with springtime triggers
PSH None
Allergies None
, Freshman student at the University of Awesome located in central Illinois. Home is
Social
in Phoenix.
Habits Denies cigarettes +recreational marijuana use +drinks 3-6 beers per weekend
FH Adopted, does not know biological parents history
Physical exam reveals the following.
Physical Exam
Constitutional Young adult male in NAD, alert and oriented, cooperative
VS Temp-97.9, P-68, R-16, BP 120/75, Height 6'0, Weight 195 pounds
Head Normocephalic
Visual Acuity 20/20 (uncorrected) OU. PERRL with white sclera bilaterally.
Slight light sensitivity noted bilaterally. No crusting, lesions or masses on lids
noted. Bilateral conjunctiva with diffuse redness and tearing but no mucoid or
purulent drainage noted. No visible FBs under lids or on cornea to gross
Eyes examination.
Fundiscopic examination: Discs flat with sharp margins. Vessels present in all
quadrants without crossing defects. Retinal background has even color, no
hemorrhages noted. Macula has even color.
Tympanic membranes gray and intact with light reflex noted. Pinna and tragus
Ears
nontender.
Nares patent. Nasal turbinates are pale and boggy with mild to moderate
Nose
swelling. Nasal drainage is clear.
Oropharynx moist, no lesions or exudate. Tonsils ¼ bilaterally. Teeth in good
Throat
repair, no cavities noted.
Neck supple. No lymphadenopathy. Thyroid midline, small and firm without
Neck
palpable masses.
Heart S1 and S2 noted, no murmurs, noted. Lungs clear to auscultation
Cardiopulmonary
bilaterally. Respirations unlabored.
1. Briefly and concisely summarize the history and physical (H&P) findings as if you were
presenting it to your preceptor using the pertinent facts from the case. Use shorthand
where possible and approved medical abbreviations. Avoid redundancy and irrelevant
information.
2. Provide a differential diagnosis (minimum of 3) which might explain the patient's chief
complaint along with a brief statement of pathophysiology for each.
3. Analyze the differential by using the pertinent findings from the history and physical to
argue for or against a diagnosis.
4. Rank the differential in order of most likely to least likely.
5. Identify any additional tests and/or procedures that you feel is necessary or needed to
help you narrow your differential. All testing decisions must be supported with an
evidence-based medicine (EBM) argument as to why it is necessary or pertinent in this
case. If no testing is indicated or needed, you must also support this decision with EBM
evidence.
