Exam (elaborations) NR 511 Week 1 DQ2 Discussion Part Two Mary 44 YO

Exam (elaborations) 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. Allergies: NKDA. PMHx: Denies past illness or injuries. Hospitalized times 2 for childbirth, no surgeries. Drinks alcohol socially, denies tobacco or illicit drug use. Sleeps 6-7 hours/night. 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. Fam Hx: John and Patrick smoke but not in the home. She has 2 siblings that are in good health. 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. ROS: Constitutional: Denies weight loss, fever, chills, weakness or fatigue. 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. Cardiovascular/Respiratory: No reports of chest pain, palpitation, or dizziness. No reports of wheezing, shortness of breath or cough. 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 from CourseH on :48:40 GMT -05:00 This study resource was shared via CourseH NR 511 Week 1 DQ2 Discussion Part Two Mary 44 YO 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. 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. Macula has even color Ears: Tympanic membranes intact with bubbles noted. Pinna and tragus nontender. 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 lymphadenopathy noted bilaterally. Thyroid midline, small and firm without palpable masses. 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 fields. No organomegaly noted. Allergies: NKDA. Diagnostic Results: adenovirus rapid screening test: negative A. DIAGNOSIS: 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 from CourseH on :48:40 GMT -05:00 This study resource was shared via CourseH DIFFERENTIAL DIAGNOSES: Allergic Conjunctivitis (ICD 10-H10.45) Adenoviral conjunctivitis (ICD 10-B30.1) P: PLAN 1. Medications. Polymyxin B Sulfate / Bacitracin should be prescribed to Mary and she should apply an 0.5 inch ribbon of ointment to lower conjunctival sac of affected eyes every 3-4 hours; continue therapy for 48 hours after symptoms cease (Micromedex, 2016) 2. Additional diagnostic test. Laboratory tests to identify bacteria and sensitivity to antibiotics are performed only in patients with severe cases, in patients with immune compromise, in contact lens wearers, in neonates, and when initial treatment fails (Cronau, Kankanala & Mauger, 2012). 3. Education. Mary should return to the office if symptoms do not improve, the eyelid becomes red, swollen, warm, tender or painful, or if the vision becomes blurred (Micromedex, 2016). Patients remain infectious for 10 to 12 days after the onset of symptoms. 4. Referrals. Mary will be promptly referred to an ophthalmologist if her symptoms to not improve or she occurs visual loss; moderate or severe pain; severe, purulent discharge; corneal involvement; conjunctival scarring; lack of response to therapy; recurrent episodes; or a history of herpes simplex virus eye disease (Micromedix, 2016). 5. Follow up. Mary with be scheduled to follow up with her primary care physician in 48 hours so her symptoms can be monitored (Micromedix, 2016). MaryKate , 7-year-old Caucasian, female. S. CC: Patient has complaint of having a red eye for 2 days that started in her left eye and spread to her right eye this morning. HPI: Onset: 2 days ago Location: Bilateral Eyes Duration: constant redness in left eye that spread to right eye Characteristics: Itching and burning. Aggravating Factors: Nothing seems to make it worse. Relieving Factors: Nothing seems to make it better. This study source was downloaded by from CourseH on :48:40 GMT -05:00 This study resource was shared via CourseH Treatment: Tried Visine eye drops which burned and did not help with the drainage or redness. Current Medications: Was given OTC medication for congestion for a cold she had that lasted about a week. Allergies: NKDA. PMHx: No past illnesses or surgeries. Up to date on vaccination per medical record. Soc Hx: Second grader at the local parochial school and is considered a good student. MaryKate live with her parents Mary and Patrick, and she has 3 siblings that also live in the home. Her grandparents, John and Katie are retired and also live in the home John and Patrick smoke but not in the home. Fam Hx: MaryKate parents are in good health. Her father and grandfather are smokers but no in the home. Her grandparents, 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. ROS: Constitutional: No reports of weight loss, fever, chills, weakness or fatigue. HEENT: No reports of headache, fever, vision changes, ear pain, hearing loss, or ringing in the ears. Nasal congestion is improving, nasal discharge is clear. No report of sore throat, difficulty swallowing. Cardiovascular/Respiratory: : No reports of chest pain, palpitation, or dizziness. No reports of wheezing, shortness of breath or cough. 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. O. Physical exam V.S. height: 46 inches, weight 46 pounds BMI 16.7; BP 82/50 T 99.0 P 92, regular RR 20. General Appearance: Patient is a 7 year old Caucasian girl who is alert, oriented and answers questions appropriately. HEENT: Head: head normocephalic. Hair thick with distribution throughout scalp. This study source was downloaded by from CourseH on :48:40 GMT -05:00 This study resource was shared via CourseH 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. 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. Macula has even color. Ears: Tympanic membranes intact with bubbles noted. Pinna and tragus nontender. 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 lymphadenopathy noted bilaterally. Thyroid midline, small and firm without palpable masses. 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 fields. No organomegaly noted. Allergies: NKDA. Diagnostic Results: adenovirus rapid screening test: positive A. DIAGNOSIS: Primary Diagnosis- Adenoviral conjunctivitis (ICD-10 B30.1) Adenoviral conjunctivitis (Ad-CS), also known as “pink eye,” is one of the most common eye infections worldwide. Ad-CS is highly symptomatic, causing discomfort, tearing, lid swelling, photophobia, and decreased vision. MaryKate’s symptoms include eye redness, itching and burning which are characteristic of conjunctivitis. She received an adenovirus rapid test which was positive and this indicates that the viral particles have entered cells in the eye, replicated and produced infectious prodigy virions. DIFFERENTIAL DIAGNOSES: Allergic Conjunctivitis (ICD-10-H10.45) Bacterial Conjunctivitis (ICD-10-H10.023) P: PLAN. Currently there are no drugs that are FDA approved for use in the management of adenoviral conjunctivitis. In severe cases, anti-inflammatory and anti-immune therapies are desirable for reducing irritation, visual disturbances, photophobia, pain, lid swelling, chemosis and psuedomembranes and for preventing the formation of subepithelial immune corneal infiltrates (Than, Hartwick, Shorter & Johnson, 2014). This study source was downloaded by from CourseH on :48:40 GMT -05:00 This study resource was shared via CourseH 1. Medications. The use of topical ganciclovir 0.15% can be prescribed to use in the affected eye 5 times daily (about every 3 hours while awake) is currently being investigated and is currently being prescribed as a treatment for adenoviral conjunctivitis (Chou & Hong, 2014). 2. Additional diagnostic test. Cultures are useful in cases that do not respond to therapy, cases of hyperacute conjunctivitis, and suspected chlamydial conjunctivitis (Azari & Barney, 2013). 3. Education. MaryKate should return to the office if symptoms do not improve, the eyelid becomes red, swollen, warm, tender or painful, or if the vision becomes blurred (Micromedix, 2016). Patients remain infectious for 10 to 12 days after the onset of symptoms. 4. Referrals. MaryKate will be promptly referred to an ophthalmologist if her symptoms to not improve or she occurs visual loss; moderate or severe pain; severe, purulent discharge; corneal involvement; conjunctival scarring; lack of response to therapy; recurrent episodes; or a history of herpes simplex virus eye disease (Micromedix, 2016). 5. Follow up. MaryKate with be scheduled to follow up with her primary care physician in 4