Week 3: Clinical Case Study Part One Discussion
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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
Both eyes feel "gritty" with mild to moderate amount of discomfort. Further describes
Characteristics
the gritty sensation "like sand caught in your eye"
Aggravating
None identified
factors
Relieving
None identified
factors
Tried OTC visine drops once yesterday which temporarily improved the redness but
Treatments the gritty sensation, tearing and itching remained.
Severity Level of discomfort is 2/10 on pain scale
Review of Systems (ROS)
Denies fever, chills, or recent illnesses
Constitutional
Denies contact lenses or glasses, has never experienced these symptoms
previously. Last eye exam was "a few years ago". Denies eye injury, trauma, visual
Eyes
changes or dryness. Denies crusting of lids or mucoid or purulent drainage. Bilateral
symptoms of +redness, +itching, +tearing + FB sensation.
Ears -otalgia, -otorrhea
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https://www.coursehero.com/file/39920171/Case-study-wk-3-A-and-3B-finaldocx/
, +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
Nose
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
Loratadine 10mg daily and fluticasone nasal spray daily (only takes during the spring
Medications
months when nasal allergies flare)
PMH Seasonal allergic rhinitis with springtime triggers
PSH None
Allergies None
Freshman student at the University of Awesome located in central Illinois. Home is in
Social
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
This study source was downloaded by 100000770861734 from CourseHero.com on 02-09-2022 11:53:36 GMT -06:00
https://www.coursehero.com/file/39920171/Case-study-wk-3-A-and-3B-finaldocx/
No unread replies. No replies.
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
Both eyes feel "gritty" with mild to moderate amount of discomfort. Further describes
Characteristics
the gritty sensation "like sand caught in your eye"
Aggravating
None identified
factors
Relieving
None identified
factors
Tried OTC visine drops once yesterday which temporarily improved the redness but
Treatments the gritty sensation, tearing and itching remained.
Severity Level of discomfort is 2/10 on pain scale
Review of Systems (ROS)
Denies fever, chills, or recent illnesses
Constitutional
Denies contact lenses or glasses, has never experienced these symptoms
previously. Last eye exam was "a few years ago". Denies eye injury, trauma, visual
Eyes
changes or dryness. Denies crusting of lids or mucoid or purulent drainage. Bilateral
symptoms of +redness, +itching, +tearing + FB sensation.
Ears -otalgia, -otorrhea
This study source was downloaded by 100000770861734 from CourseHero.com on 02-09-2022 11:53:36 GMT -06:00
https://www.coursehero.com/file/39920171/Case-study-wk-3-A-and-3B-finaldocx/
, +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
Nose
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
Loratadine 10mg daily and fluticasone nasal spray daily (only takes during the spring
Medications
months when nasal allergies flare)
PMH Seasonal allergic rhinitis with springtime triggers
PSH None
Allergies None
Freshman student at the University of Awesome located in central Illinois. Home is in
Social
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
This study source was downloaded by 100000770861734 from CourseHero.com on 02-09-2022 11:53:36 GMT -06:00
https://www.coursehero.com/file/39920171/Case-study-wk-3-A-and-3B-finaldocx/
