FNP NR511 Week 3 Case Study Part 2

FNP NR511 Week 3 Case Study Part 2

FNP NR511 Week 3 Case Study Part 2

Patient with bilateral eye discomfort.

Patient information:

A 19-year-old male

Subjective.

CC (chief complaint): Bilateral eye discomfort.
HPI (history of present illness): The patient is a 19-year-old male who presents with complaints of eye discomfort. The patient reports that this discomfort started 2-3 days ago. He reports that both eyes are affected and characterizes the discomfort as constant. He describes it further by saying that the eyes feel ‘gritty’. He goes on to describe the gritty sensation as feeling as if sand is caught in between the eyes. He reports no aggravating or relieving factors.

The patient took OTC visine drops once yesterday and he says that this improved the redness temporarily. There were however no changes with the gritty sensation, tearing and itching. The patient describes the severity of discomfort on a pain scale of 2/10. The patient reports that he has never experienced these symptoms before.

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Current Medications: Visine OTC once yesterday.

Allergies: no known allergies

PMH: Seasonal allergic rhinitis.  This is well controlled on fluticasone nasal spray daily and Loratadine 10mg daily. He only takes these medications during the spring months when nasal allergies flare.

FH:  unavailable. Patient is adopted  
SH : A freshman at the University of Awesome. Does not use tobacco. Drinks 3-6 beers per weekend. Uses recreational marijuana. FNP NR511 Week 3 Case Study Part 2

ROS

GENERAL: The patient has no constitutional symptoms like fever or chills.  

HEENT:

Head: Atraumatic, normocephalic.

Eyes: Does not use contact lenses or glasses. No visual changes. Negative for eye injury, or trauma. No dryness. No crusting of lids. No mucoid or purulent drainage. Has bilateral symptoms of itchiness, tearing, and redness of the eyes. Has FB sensation in the eyes. FNP NR511 Week 3 Case Study Part 2

Ears: No otalgia. No otorrhea.

Nose: positive for runny nose. Positive for nasal congestion. Negative for sneezing,

Throat: No ST and redness.

CARDIOVASCULAR: no chest pain

RESPIRATORY: No cough, SOB and wheezing

NEUROLOGICAL: patient is alert and oriented.

LYMPHATICS: No lymphadenopathy.

 

Objective. FNP NR511 Week 3 Case Study Part 2

Physical exam:

Vitals: Temperature is 97.9.  Pulse is 68 bpm. Respiratory rate is 16 breathes per minute. BP is 120/75, Weight 195 pounds, Height 6\’0,

General: A young adult male in NAD. He is alert, oriented, and cooperative. 

HEENT:

Head: Atraumatic, normocephalic.

Eyes: PERRL with white sclera bilaterally. Slight bilateral photophobia. Visual Acuity 20/20 (uncorrected) OU. Positive for bilateral conjunctival redness and tearing. Negative for mucoid or purulent drainage. No crusting of lids. No masses or lesions on lids. No visible foreign bodies under lids or on cornea.

Fundoscopic examination: retina is normal. No retinal hemorrhages.

Ears: gray and intact tympanic membranes. Pinna and tragus nontender.

Nose: Nares are patent. Pale and boggy nasal turbinates. Nasal mucosa has thin clear secretions.

Throat: Moist oropharynx, no lesions or exudate. Signs of tonsillar hypertrophy with tonsils ¼ bilaterally.

RESPIRATORY: Lungs fields clear bilaterally. No difficulty in breathing

CARDIOVASCULAR: S1 and S2 heard. No murmurs.

NECK: Supple. Thyroid midline, small, and firm with no palpable masses.

LYMPHATICS: No signs of lymphadenopathy.

 

FNP NR511 Week 3 Case Study Part 2 Assessment.

Differential diagnosis: based on the symptoms and physical exam findings, the differential diagnoses are:

FNP NR511 Week 3 Case Study Part 2

  1. Allergic conjunctivitis. This is an inflammation of the conjunctiva due to an allergic reaction. The same allergens that usually trigger allergic rhinitis can also trigger allergic conjunctivitis. This is because the conjunctiva is a mucosal surface.  The patient has a positive history of allergic rhinitis and it is therefore possible that the same allergens responsible for allergic rhinitis could have caused the allergic conjunctivitis. The patient’s symptoms also support this diagnosis. He presents with bilateral itching of the eyes, redness, discomfort, and tearing of the eyes. These are definitive symptoms of allergic rhinitis. Allergic reactions rarely occur without itchiness and lack of itchiness makes a diagnosis of allergic conjunctivitis suspect (Bielory et al., 2020 FNP NR511 Week 3 Case Study Part 2). Physical examination of the eyes elicits a slight sensitivity to light. This is also a common finding in allergic conjunctivitis.
  2. Allergic rhinitis. Allergic rhinitis usually involves the inflammation of nasal membranes. Allergic rhinitis is also strongly linked to the inflammation of the conjunctiva. It is an atopic disease that occurs as a result of an inflammatory process triggered by an allergen. The defining symptoms of allergic rhinitis are rhinorrhea, itchiness of the eyes, nose and palate, nasal congestion and postnasal drip (Gardiner, 2018 FNP NR511 Week 3 Case Study Part 2). The patient presents with majority of these symptoms. Physical examination reveals that the nasal turbinates are pale and boggy with mild to moderate swelling. This is a typical sign of allergic rhinitis.
  3. Viral conjunctivitis, also known as pink eye. This is a common condition that is usually caused by viral infection of the eyes.  The common signs associated with the disease is itchiness of the eyes, tearing, redness of the eyes, discharge and light sensitivity (Yeu & Hauswirth, 2020). Light sensitivity usually indicates corneal involvement. The presence of these symptoms in this patient supports this diagnosis.

 

Diagnostic tests:

  1. Complete blood count (CBC): to rule out infections and check the eosinophil count
  2. In vitro allergy testing to determine the amount of specific IgE.
  3. Allergy skin test

 

FNP NR511 Week 3 Case Study Part 2 References

Bielory, L., Delgado, L., Katelaris, C. H., Leonardi, A., Rosario, N., & Vichyanoud, P. (2020). ICON: diagnosis and management of allergic conjunctivitis. Annals of Allergy, Asthma & Immunology, 124(2), 118-134. https://doi.org/10.1016/j.anai.2019.11.014

Gardiner, Q. (2018). Allergic rhinitis. Scott-Brown’s Otorhinolaryngology Head and Neck Surgery, 999-1010. http://dx.doi.org/10.1201/9780203731031-92

Yeu, E., & Hauswirth, S. (2020). A Review of the Differential Diagnosis of Acute Infectious Conjunctivitis: Implications for Treatment and Management. Clinical Ophthalmology (Auckland, N.Z.), 14, 805–813. https://doi.org/10.2147/OPTH.S236571

FNP NR511 Week 3 Case Study Part 2 Requirements:

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.
Provide a differential diagnosis (minimum of 3) which might explain the patient\’s chief complaint along with a brief statement of pathophysiology for each.
Analyze the differential by using the pertinent findings from the history and physical to argue for or against a diagnosis. FNP NR511 Week 3 Case Study Part 2
Rank the differential in order of most likely to least likely.
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.
Case StudyDate of visit: October 20, 2017A 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. FNP NR511 Week 3 Case Study Part 2

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. FNP NR511 Week 3 Case Study Part 2

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). FNP NR511 Week 3 Case Study Part 2
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 FNP NR511 Week 3 Case Study Part 2)
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. FNP NR511 Week 3 Case Study Part 2

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.

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