NR 511 Week 1 DQ2 Discussion Part
Two Mary 44 YO
Discussion Part Two
Mary , 44-year-old Caucasian, female.
S.
CC: Patient has complaint of goop in the eye and eye being red.
HPI:
Onset: This morning (1 day)
Location: Eye
Duration: constant redness
Characteristics: Eye drainage
Aggravating Factors: Nothing seems to make it worse.
Relieving Factors: Nothing seems to make it better.
Treatment: Has not tried any home remedies.
Current Medications: Takes a daily multivitamin and a B complex supplement.
m
er as
Allergies: NKDA.
co
eH w
PMHx: Denies past illness or injuries. Hospitalized times 2 for childbirth, no surgeries. Drinks
o.
alcohol socially, denies tobacco or illicit drug use. Sleeps 6-7 hours/night.
rs e
ou urc
Soc Hx: Mary is a high school graduate and works full time at a local business in the ordering
department. Mary lives with her husband, Patrick, 4 children, and her parents Katie and John
who are retired.
o
aC s
Fam Hx: John and Patrick smoke but not in the home. She has 2 siblings that are in good health.
vi y re
Her parents Katie and John emigrated from Ireland in their 20’s and have always lived in this
area. Katie has history of HTN and hyperlipidemia. John has a history of tobacco use since age
10, HTN and hyperlipidemia. They also share their home with 2 dogs and a cat.
ed d
ROS:
ar stu
Constitutional: Denies weight loss, fever, chills, weakness or fatigue.
is
HEENT: No reports of headache, fever, vision changes, ear pain, hearing loss, or ringing in the
ears. No reports of nasal congestion, or discharge; no report of sore throat, difficulty swallowing.
Th
Cardiovascular/Respiratory: No reports of chest pain, palpitation, or dizziness. No reports of
wheezing, shortness of breath or cough.
sh
Gastrointestinal: No reports anorexia, nausea, vomiting, diarrhea or abdominal pain.
Neck/Lymphatic: No reports of enlarged lymph nodes.
Allergies: No reports of asthma, hives or eczema.
This study source was downloaded by 100000829244943 from CourseHero.com on 08-28-2021 04:48:40 GMT -05:00
https://www.coursehero.com/file/22710043/NR511-Week-1-DQ2/
, O.
Physical exam
V.S. height: 64 in, weight 149 pounds BMI 26.4. BP 126/72, Temp 98.5, P 72, regular and RR
12.
General Appearance: Patient is a 44 year old Caucasian woman who is alert, oriented and
cooperative.
HEENT:
Head: head normocephalic. Hair thick with distribution throughout scalp.
Eyes: Vision testing by Snellen chart- right eye: 20/40, left 20/40, together 20/30. No ptsosis. No
lesions noted. Brows and lashes present. Tearing noted bilaterally, Conjunctiva red bilaterally,
PERRLA, EOMs intact. Eyelids without erythema, no crusting noted on eyelashes.
m
er as
Fundi: red reflex present bilaterally, Discs flat with sharp margins. Vessels present in all
quadrants without crossing defects. Retinal background has even color, no hemorrhages noted.
co
eH w
Macula has even color
o.
Ears: Tympanic membranes intact with bubbles noted. Pinna and tragus nontender.
rs e
ou urc
Throat/Mouth: Oropharynx moist, no exudate. Teeth in good repair, no cavities noted. Tonsils
¼ bilaterally.
Neck/Lymphatic: Sinuses nontender to palpation. Neck supple. Mild anterior cervical
o
lymphadenopathy noted bilaterally. Thyroid midline, small and firm without palpable masses.
aC s
vi y re
Cardiovascular/Respiratory: Heart S1 and s2 noted, no murmurs, noted. Lungs clear to
auscultation bilaterally. Respirations unlabored.
Gastrointestinal: Abdomen soft, nontender, bowel sounds auscultated in all four quadrants
ed d
fields. No organomegaly noted.
ar stu
Allergies: NKDA.
is
Diagnostic Results: adenovirus rapid screening test: negative
Th
A.
DIAGNOSIS:
sh
Primary Diagnosis- Bacterial Conjunctivitis (ICD-10-H10.023)
Bacterial conjunctivitis is an infection most often caused by staphylococcal or streptococcal
bacteria from your own skin or respiratory system and produces symptoms such as Discharge
from one or both eyes, Swollen eyelids and Pink discoloration to the whites of one or both eyes.
Mary presents with goop and redness in the eye (AOA, 2016).
This study source was downloaded by 100000829244943 from CourseHero.com on 08-28-2021 04:48:40 GMT -05:00
https://www.coursehero.com/file/22710043/NR511-Week-1-DQ2/
Two Mary 44 YO
Discussion Part Two
Mary , 44-year-old Caucasian, female.
S.
CC: Patient has complaint of goop in the eye and eye being red.
HPI:
Onset: This morning (1 day)
Location: Eye
Duration: constant redness
Characteristics: Eye drainage
Aggravating Factors: Nothing seems to make it worse.
Relieving Factors: Nothing seems to make it better.
Treatment: Has not tried any home remedies.
Current Medications: Takes a daily multivitamin and a B complex supplement.
m
er as
Allergies: NKDA.
co
eH w
PMHx: Denies past illness or injuries. Hospitalized times 2 for childbirth, no surgeries. Drinks
o.
alcohol socially, denies tobacco or illicit drug use. Sleeps 6-7 hours/night.
rs e
ou urc
Soc Hx: Mary is a high school graduate and works full time at a local business in the ordering
department. Mary lives with her husband, Patrick, 4 children, and her parents Katie and John
who are retired.
o
aC s
Fam Hx: John and Patrick smoke but not in the home. She has 2 siblings that are in good health.
vi y re
Her parents Katie and John emigrated from Ireland in their 20’s and have always lived in this
area. Katie has history of HTN and hyperlipidemia. John has a history of tobacco use since age
10, HTN and hyperlipidemia. They also share their home with 2 dogs and a cat.
ed d
ROS:
ar stu
Constitutional: Denies weight loss, fever, chills, weakness or fatigue.
is
HEENT: No reports of headache, fever, vision changes, ear pain, hearing loss, or ringing in the
ears. No reports of nasal congestion, or discharge; no report of sore throat, difficulty swallowing.
Th
Cardiovascular/Respiratory: No reports of chest pain, palpitation, or dizziness. No reports of
wheezing, shortness of breath or cough.
sh
Gastrointestinal: No reports anorexia, nausea, vomiting, diarrhea or abdominal pain.
Neck/Lymphatic: No reports of enlarged lymph nodes.
Allergies: No reports of asthma, hives or eczema.
This study source was downloaded by 100000829244943 from CourseHero.com on 08-28-2021 04:48:40 GMT -05:00
https://www.coursehero.com/file/22710043/NR511-Week-1-DQ2/
, O.
Physical exam
V.S. height: 64 in, weight 149 pounds BMI 26.4. BP 126/72, Temp 98.5, P 72, regular and RR
12.
General Appearance: Patient is a 44 year old Caucasian woman who is alert, oriented and
cooperative.
HEENT:
Head: head normocephalic. Hair thick with distribution throughout scalp.
Eyes: Vision testing by Snellen chart- right eye: 20/40, left 20/40, together 20/30. No ptsosis. No
lesions noted. Brows and lashes present. Tearing noted bilaterally, Conjunctiva red bilaterally,
PERRLA, EOMs intact. Eyelids without erythema, no crusting noted on eyelashes.
m
er as
Fundi: red reflex present bilaterally, Discs flat with sharp margins. Vessels present in all
quadrants without crossing defects. Retinal background has even color, no hemorrhages noted.
co
eH w
Macula has even color
o.
Ears: Tympanic membranes intact with bubbles noted. Pinna and tragus nontender.
rs e
ou urc
Throat/Mouth: Oropharynx moist, no exudate. Teeth in good repair, no cavities noted. Tonsils
¼ bilaterally.
Neck/Lymphatic: Sinuses nontender to palpation. Neck supple. Mild anterior cervical
o
lymphadenopathy noted bilaterally. Thyroid midline, small and firm without palpable masses.
aC s
vi y re
Cardiovascular/Respiratory: Heart S1 and s2 noted, no murmurs, noted. Lungs clear to
auscultation bilaterally. Respirations unlabored.
Gastrointestinal: Abdomen soft, nontender, bowel sounds auscultated in all four quadrants
ed d
fields. No organomegaly noted.
ar stu
Allergies: NKDA.
is
Diagnostic Results: adenovirus rapid screening test: negative
Th
A.
DIAGNOSIS:
sh
Primary Diagnosis- Bacterial Conjunctivitis (ICD-10-H10.023)
Bacterial conjunctivitis is an infection most often caused by staphylococcal or streptococcal
bacteria from your own skin or respiratory system and produces symptoms such as Discharge
from one or both eyes, Swollen eyelids and Pink discoloration to the whites of one or both eyes.
Mary presents with goop and redness in the eye (AOA, 2016).
This study source was downloaded by 100000829244943 from CourseHero.com on 08-28-2021 04:48:40 GMT -05:00
https://www.coursehero.com/file/22710043/NR511-Week-1-DQ2/
