NR 511 Week 3 Case Study Part I Differential Diagnosis & Primary Care Practicum A+
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Course
NR 511
Institution
NR 511
NR 511 Week 3 Case Study Part I
Differential Diagnosis & Primary
Care Practicum A+NR 511 Week 3 Case Study Part I
Differential Diagnosis & Primary
Care Practicum A+
NR 511 Week 3 Case Study Part I
Differential Diagnosis & Primary
Care Practicum A+
, Week 3 Case Study Part I
H&P Findings:
My patient is a 19yo male who presents with constant, bilateral eye pain on a numerical scale of
2/10 that describes the pain as “gritty and “sand in the eye feeling” for the past 2-3 days. Pt has
tried OTC visine gtts which only provided temporary relief of redness, but the “gritty “feeling,
tearing, FB sensation and itching remained. Pt has intermittent nasal drainage/congestion. No
crusting of the eyelids, mucus or purulent drainage has been noted. Pt denies any eye injuries,
trauma, vision changes or dryness.
History:
Pt has a PMH of seasonal allergies, no PSH, NKA. Pt is adopted so no biological parent history
was able to be obtained. Constitution was unremarkable. Denies wearing contact lenses or
glasses. Last year eye exam was normal. Denies Sore throat or redness. No lymphadenopathy or
swelling in the neck. Denies cough, SOB, CP, or wheezing. Pt takes Loratadine 10mg PO daily
which normally controls his symptoms and uses Fluticasone nasal spray PRN during the
springtime when there are allergy flares. There has been no aggravating or relieving factors.
Denies smoking cigarettes but admits to recreational marijuana usage and drinking 3-6 beers
during the weekend.
Physical exam:
19yo male pt. AOX4, who appears to be a healthy, cooperative, and good historian. V/S: Temp
97.9, P-68, RR-16, BP- 120/75. Ht: 72”, Wt.: 195lbs (88.6Kg). Visual acuity was 20/20
uncorrected.
Bilateral conjunctiva clear eye drainage, redness and tearing. No visible FBs under lids or on
cornea to gross examination. Discs found to be flat with sharp margins. Vessels present in all 4
quadrants without crossing defects. Retina and macula background has even color, no
hemorrhages noted. Pinna and tragus non-tender. Tympanic membranes are gray, intact with
light reflex noted. Nares are patent with clear nasal drainage. Turbinates are noted to be pale and
boggy with mild to moderate swelling. Neck is supple. Thyroid is midline, small, firm and
without palpable masses. Oropharynx is noted to be moist, no lesions noted or exudate. Tonsils
are ¼ bilaterally. Teeth are in good condition with no dental caries noted. S1 and S2 noted, no
murmurs or gallops noted. Lungs CTA with no further remarkable findings.
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