NR 511 DISCUSSION PART 1 WEEK 3 (PERTINENT INFORMATION) (NR511)

Exam (elaborations) NR 511 DISCUSSION PART 1 WEEK 3 (PERTINENT INFORMATION) (NR511) 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 Medication s 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 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