FNP NR 511 CASE STUDY WK 3A AND 3B FINAL.

FNP NR 511 CASE STUDY WK 3A AND 3B FINAL. Week 3: Clinical Case Study Part One Discussion No unread replies. No replies. Date of visit: October 20, 2017 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 Characteristics Both eyes feel "gritty" with mild to moderate amount of discomfort. Further describes the gritty sensation "like sand caught in your eye" Aggravating factors None identified Relieving factors None identified Treatments Tried OTC visine drops once yesterday which temporarily improved the redness but the gritty sensation, tearing and itching remained. Severity Level of discomfort is 2/10 on pain scale Review of Systems (ROS) Constitutional Denies fever, chills, or recent illnesses Eyes Denies contact lenses or glasses, has never experienced these symptoms previously. Last eye exam was "a few years ago". Denies eye injury, trauma, visual changes or dryness. Denies crusting of lids or mucoid or purulent drainage. Bilateral symptoms of +redness, +itching, +tearing + FB sensation. Ears -otalgia, -otorrhea Nose +occasional runny nose with intermittent nasal congestion, denies sneezing. History of seasonal nasal allergies which is aggravated in the spring but is well 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 Medications Loratadine 10mg daily and fluticasone nasal spray daily (only takes during the spring months when nasal allergies flare) PMH Seasonal allergic rhinitis with springtime triggers PSH None Allergies None Social Freshman student at the University of Awesome located in central Illinois. Home is 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 Eyes 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 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. Ears Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender. Nose Nares patent. Nasal turbinates are pale and boggy with mild to moderate swelling. Nasal drainage is clear. Throat Oropharynx moist, no lesions or exudate. Tonsils ¼ bilaterally. Teeth in good repair, no cavities noted. Neck Neck supple. No lymphadenopathy. Thyroid midline, small and firm without palpable masses. Cardiopulmonary Heart S1 and S2 noted, no murmurs, noted. Lungs clear to auscultation 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. Pt is a 19yo male presenting with complaint of bilateral eye discomfort with some pain, as well as redness, itching, FB sensation, and tearing. Pt states that symptoms began 2-3 days ago, with characteristics of “gritty” sensation “like sand” which is of constant duration. Pt has tried Visine eyes drops which helped initially but only by relieving redness and only for a short time. Pt reports previous eye exam as “a few years ago”, denies use of contacts or glasses, pain, crusting, mucous, or injury of either eye. Denies ear pain or drainage, reports some rhinorrhea with congestion, denies sneezing, cough, sore throat, fever, chills, wheezing, SOB, CP. Reports occasional marijuana use and alcohol use of 3-6 beers per weekend. Pt reports history of seasonal springtime allergies for which he takes daily Loratadine 10mg and Fluticasone but he has not been taking these recently. Physical exam reveals visual acuity 20/20 OU, PERRL, white sclera OU. Slight photophobia with diffuse conjunctival redness and tearing noted bilaterally, no crusting or purulent discharge noted. No obvious FB or lesions noted bilaterally. Fundoscopic examination unremarkable. Boggy, pale nasal turbinates with mild to moderate edema and clear drainage. Physical examination otherwise negative. 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. Dry Eye Disease (DED) -DED is caused by inadequate tears which lubricate and protect the eye. This condition can be caused either by a lack of production, or due to an imbalance in the chemical structure of tears produced. This dysfunction results in decreased lubrication of the eye causing dryness and inability of the eye to cleans and protect from foreign materials such as dust and pollen, ultimately leading to the characteristic dry and gritty feeling associated with the condition (Hessen & Apkek, 2014). Allergic Rhinoconjunctivitis (AR) -Allergic conjunctivits is extremely common and is caused by IgE mast cell response to environmental allergens such as pollution, pollen, or other allergen causing stimuli. This process results in histamine release and hyper-response of immune cells resulting in inflammation including itching, increased lacrimation, FB sensation, redness, and photophobia. This condition most commonly occurs bilaterally and, when accompanied by nasal symptoms, is termed allergic rhinoconjunctivitis (Ackerman, Smith, & Gomes, 2016). Infectious Conjunctivitis (IC) -Infectious conjunctivitis can be due to bacterial or viral infection and is usually unilateral or, in cases of bilateral infection, begins unilaterally and spreads to the other eye over the course of a few days. Causative agents for bacterial infection include staphylococci, streptococci, or pneumococci, and herpes simplex for viral infection. In addition to unilateral presentation, IC is often associated with watery (viral) or mucopurulent (bacterial) discharge, severe pain, itching, redness, visual disturbance, and photophobia (Frings, A., Geerling, G., & Schargus, 2017) 3. Analyze the differential by using the pertinent findings from the history and physical to argue for or against a diagnosis. This patient presents with acute, bilateral symptoms which include itchiness, redness, watery discharge, 2/10 pain, FB sensation, and accompanied by runny nose. These symptoms are least associated with IC as this is acute, bilateral, and lacks purulent discharge, visual disturbance, and severe pain. The patient symptoms are associated with both DED and AR. However, the history of allergies, lack of medication compliance, and associated rhinorrhea make the diagnosis of AR more appropriate than that of DED. Although pt allergy symptoms have historically occurred in spring, the patient has recently moved from Arizona to Chicago to attend college. These areas of the country vary drastically in climate and it is likely that there may be a new allergen causing his symptoms to occur in the fall in this new environment. 4. Rank the differential in order of most likely to least likely. Allergic rhinoconjunctivitis Dry Eye Infectious Conjunctivitis 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. Diagnosis of AR is often made based upon combination of symptoms and history. Conservative approach with the use of antihistamine medication. Allergy testing is often costly and, though this may be necessary, should be considered only after treatment has not provided relief (Dunphy, 2015). References Ackerman, S., Smith, L. M., & Gomes, P. J. (2016). Ocular itch associated with allergic conjunctivitis: latest evidence and clinical management. Therapeutic advances in chronic disease, 7(1), 52-67. Dunphy, L. M. (2015). Primary care: The art and science of advanced practice nursing (4th ed.). Philadelphia, PA: F.A. Davis. Frings, A., Geerling, G., & Schargus, M. (2017). Red Eye: A Guide for Non-specialists. Deutsches Arzteblatt international, 114(17), 302-312. Hessen, M., & Akpek, E. K. (2014). Dry eye: an inflammatory ocular disease. Journal of ophthalmic & vision research, 9(2), 240-50. Week 3: Clinical Case Study Part Two Discussion Now, assume that any procedures and/or testing which were performed are NORMAL. 1. What is your primary (one) diagnosis for this patient at this time? (support the decision for your diagnosis with pertinent positives and negatives from the case) Diagnosis: Allergic conjunctivitis Rationale: Since there is no diagnostic testing associated with diagnosis of allergic conjunctivitis, positive and negative pertinent findings are used to make a definitive diagnosis for this condition. Pertinent Pos/Neg: Patient has history of allergies, presents with bilateral itchy, reddened conjunctiva, mild bilateral eye pain, bilateral FB sensation, and increased bilateral lacrimation; these are all symptoms of allergic conjunctivitis (Varu et al., 2018). Pt is negative for corneal abrasion, purulent discharge, vision loss or changes, dryness, trauma, injury, or crusting. Primary diagnosis remains the same: allergic conjunctivitis 2. Identify the corresponding ICD-10 code. H10.45 3. Provide a treatment plan for this patient's primary diagnosis which includes: • Medication -PAZEO (olopatadine Ophthalmic Solution) 0.77% Disp: 2.5ml Sig: 1 drop to each eye once daily RF: 0 **(will write for refill after 1 wk re-check if med is managing symptoms) -Claritin (loratadine) 10mg Disp: 30 tabs Sig: 1 tablet by mouth once daily RF: as needed -Flonase (fluticasone nasal spray) 50mcg/spray Disp: 9.9ml Sig: 1-2 sprays in each nostril daily RF: 5 (Carr, Schaeffer, & Donnenfeld, 2016) • Any additional testing necessary for this particular diagnosis* No further testing is needed for the diagnosis of allergic conjunctivitis as this diagnosis is generally made based upon clinical presentation and patient history (Varu et al., 2018) • Patient education -Cold compress to bilateral eyes every 20 min as needed to help decrease pain, swelling, and itching (Bilkhu, Wolffsohn, Naroo, Roberston, & Kennedy, 2014) -Do not rub eyes -Wash hands thoroughly and frequently -Report changes/worsening of condition to provider immediately -Avoid known triggers/allergens -Take frequent breaks when reading; limit time using computers and watching television until condition is resolved -Wash sheets/linens regularly -Take medication as prescribed • Referral -Referral to allergist if condition worsens -Referral to ophthalmologist if visual disturbance occurs or if condition does not improve after one week of treatment (Pflipsen, Massaquoi, & Wolf, 2016). 4. Provide an active problem list for this patient based on the information given in the case. -Marijuana use -Alcohol consumption -Rhinitis -Seasonal Allergy -Family history deficit 5. Are there any changes that you would also make to this patient’s overall treatment plan at this time? Must provide an EBM argument for each treatment or testing decision. No further changes needed to the overall treatment plan. 6. Provide an appropriate F/U plan. Follow up in clinic in one week, seek immediate care if symptoms worsen or if visual problems manifest. -This allows time for the medication/treatment regimen to take effect and for the provider to determine if treatment is appropriate or if changes need to be made (Varu et al., 2018). References Bilkhu, P. S., Wolffsohn, J. S., Naroo, S. A., Robertson, L., & Kennedy, R. (2014). Effectiveness of Nonpharmacologic Treatments for Acute Seasonal Allergic Conjunctivitis. Ophthalmology, 121(1), 72- 78. doi:10.1016/a.2013.08.007 Carr, W., Schaeffer, J., & Donnenfeld, E. (2016). Treating allergic conjunctivitis: A once-daily medication that provides 24-hour symptom relief. Allergy & rhinology (Providence, R.I.), 7(2), 107-14. Pflipsen, M., Massaquoi, M., & Wolf, S. (2016). Evaluation of the Painful Eye. American Family Physician, 93 (12), 991-998. Varu, D., Rhee, M., Akpek, E., Amescua, G., Farid, M., Garcia-Ferrer, F… Lin, A. (2018). Conjunctivitis preferred practice pattern. American Academy of Opthalmology.