Case Study week 3 part 1
1. 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.
2. Provide a differential diagnosis (minimum of 3) which might explain the patient's
chief complaint along with a brief statement of pathophysiology for each.
3. Analyze the differential by using the pertinent findings from the history and
physical to argue for or against a diagnosis.
4. Rank the differential in order of most likely to least likely.
5. 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.
Subjective:
19-year-old Male presents today with a complaint of bilateral eye discomfort that began 2-3 days
ago. The eye discomfort is reported as a 2/10 on the pain scale and is described as a constant
“gritty” or “ like sand caught in your eye.” He further reports his eyes are itchy and have watery
drainage or tearing. He reportedly had redness but had some improvement with OTC vision
drops but only noted temporary relief of eye redness but the eye irritation continued. The patient
further denies any eye trauma, visual changes, glasses or contact and dryness that he can recall.
The patient denies any crusting or purulent drainage. He does note he has had an occasional
runny nose with intermittent congestion but no sneezing. His past medical history includes
seasonal nasal allergies which flares up only in spring and is controlled with Loratadine 10mg
daily and Fluticasone Nasal Spray daily in peak season. His last reported eye exam was
approximately 1 year ago and his vision was 20/20 in both eyes uncorrected. The patient further
denies any ear pain, throat pain or redness, fever, chills, SOB or wheezing. He further denies any
lymph node discomfort/swelling or chest pain.
The patient is a freshman in college in central Illinois and is originally from AZ. He does admit
to drinking 3-6 beers on the weekend as well as recreational marijuana use but denies smoking
cigarettes. He reports being adopted and is unaware of family history.
Objective:
Constitutional: VS T- 97.9 BP 120/75 HR 68 HT 6’0” WT 195 lbs.
Physical assessment essentially negative with the exception of noted pale and boggy nasal
turbinate’s as well as mild to moderate swelling and clear drainage. Bilateral eyes with noted
photosensitivity diffuse conjunctiva redness and tearing. Otherwise visual acuity remains 20/20
(uncorrected) bilaterally, no foreign object noted, no mass, lesions or crusting on lids.
Fundoscopic examination WNL.
Differential Diagnoses:
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, 1. Allergic Conjunctivitis/Rhinitis (Rhinoconjuctivitis)(H10.45)(J30.9) Allergic
conjunctivitis and allergic rhinitis are often diagnosed in conjunction since a majority of
the time a patient can have many of the same symptoms of the two in relation to an
exposure to a specific allergen. Allergic conjunctivitis is characterized by purpuritis,
redness, tearing, burning and photophobia (Leonardi, Castegnaro, Valerio, & Lazzarini,
2015). Allergic rhinitis is characterized by exposure to allergens and symptoms can
include rhinorrhea, nasal congestion, postnasal drip, nasal itching and cough (Siedman,
Grugel, & Lin, 2015). Since the patient is being exposed to more allergens i.e.: marijuana
smoke and other seasonal allergens since he is in a new geographical area it is highly
likely he is having increase in allergen exposure which is exacerbating his symptoms. He
has most if not all of the clinical symptoms of Allergic Rhinoconjuntivitis.
2. Common Cold (B97.89) non-specified the cause of the common cold is generally caused
by rhinovirus. The symptoms of a cold can include: cough, sore throat, nasal drainage or
congestion, conjunctivitis, low grade temp and malaise (Allan & Arroll, 2014). While our
patient has many of the symptoms associated with a common cold he does not report
fatigue or malaise or have a low-grade temp. Although among his population the virus
could be spread more easily as he is in closer proximity to more individuals causing
further spread of the virus. At this time, I do not feel this is the case.
3. Acute Sinusitis (J01.90) Sinusitis can be viral or bacterial in nature. The causes of viral
sinusitis can include rhinovirus, influenza and parainfluenza virus. Bacterial sinusitis is
usually caused by Streptococcus Pneumoniae, Haemophilus Pneumonia or Moraxella
catarralis. Viral sinusitis is characterized by nasal congestion, rhinorrhea, headache, sore
throat, low grade fever, facial or dental pain. Viral sinusitis can result from having a cold.
Bacterial sinusitis can also develop from a viral sinusitis. Bacterial sinusitis signs and
symptoms increase dramatically with increased drainage of green/yellow nasal discharge
and will possibly require treatment with an antibiotic (Rosenfeld, Piccirillo,
Chandrasekhar, Brook, I., .et al.2015). Early sinusitis could possibly be a differential
although at this juncture he has only a few of the symptoms associated with and acute
sinusitis. If his allergic rhinitis is not controlled it could possibly progress to a sinusitis at
a later time.
Plan:
The patient is most likely suffering from a seasonal allergy exacerbation. Although the scenario
does not specifically state what season it is however the patient is out of his normal environment
and there may be more allergens than he is used to and may have now simply become an issue.
However, he is a college student and eye strain could be a consideration but he also has other
symptoms that do no associate with eye strain or overuse since he is probably using more
electronic devices while in school. Although it may feel he has a foreign body bilaterally his eye
exam did not show any debris on his eyes or under the lids with all three differential diagnoses
the eyes can be irritated with a feeling of a foreign body within the eye but it is probably from
the irritation itself and dryness. I would most likely resume his normal regime of his
RX: Loratadine 10( ten) mg (1) one tab by mouth daily
Disp:# 60 ( sixty) tabs
Sig: 1( one) tab daily by mouth especially during peak allergy season
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1. 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.
2. Provide a differential diagnosis (minimum of 3) which might explain the patient's
chief complaint along with a brief statement of pathophysiology for each.
3. Analyze the differential by using the pertinent findings from the history and
physical to argue for or against a diagnosis.
4. Rank the differential in order of most likely to least likely.
5. 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.
Subjective:
19-year-old Male presents today with a complaint of bilateral eye discomfort that began 2-3 days
ago. The eye discomfort is reported as a 2/10 on the pain scale and is described as a constant
“gritty” or “ like sand caught in your eye.” He further reports his eyes are itchy and have watery
drainage or tearing. He reportedly had redness but had some improvement with OTC vision
drops but only noted temporary relief of eye redness but the eye irritation continued. The patient
further denies any eye trauma, visual changes, glasses or contact and dryness that he can recall.
The patient denies any crusting or purulent drainage. He does note he has had an occasional
runny nose with intermittent congestion but no sneezing. His past medical history includes
seasonal nasal allergies which flares up only in spring and is controlled with Loratadine 10mg
daily and Fluticasone Nasal Spray daily in peak season. His last reported eye exam was
approximately 1 year ago and his vision was 20/20 in both eyes uncorrected. The patient further
denies any ear pain, throat pain or redness, fever, chills, SOB or wheezing. He further denies any
lymph node discomfort/swelling or chest pain.
The patient is a freshman in college in central Illinois and is originally from AZ. He does admit
to drinking 3-6 beers on the weekend as well as recreational marijuana use but denies smoking
cigarettes. He reports being adopted and is unaware of family history.
Objective:
Constitutional: VS T- 97.9 BP 120/75 HR 68 HT 6’0” WT 195 lbs.
Physical assessment essentially negative with the exception of noted pale and boggy nasal
turbinate’s as well as mild to moderate swelling and clear drainage. Bilateral eyes with noted
photosensitivity diffuse conjunctiva redness and tearing. Otherwise visual acuity remains 20/20
(uncorrected) bilaterally, no foreign object noted, no mass, lesions or crusting on lids.
Fundoscopic examination WNL.
Differential Diagnoses:
This study source was downloaded by 100000836386117 from CourseHero.com on 03-08-2022 23:36:38 GMT -06:00
https://www.coursehero.com/file/32384110/Case-Study-week-3-part-1docx/
, 1. Allergic Conjunctivitis/Rhinitis (Rhinoconjuctivitis)(H10.45)(J30.9) Allergic
conjunctivitis and allergic rhinitis are often diagnosed in conjunction since a majority of
the time a patient can have many of the same symptoms of the two in relation to an
exposure to a specific allergen. Allergic conjunctivitis is characterized by purpuritis,
redness, tearing, burning and photophobia (Leonardi, Castegnaro, Valerio, & Lazzarini,
2015). Allergic rhinitis is characterized by exposure to allergens and symptoms can
include rhinorrhea, nasal congestion, postnasal drip, nasal itching and cough (Siedman,
Grugel, & Lin, 2015). Since the patient is being exposed to more allergens i.e.: marijuana
smoke and other seasonal allergens since he is in a new geographical area it is highly
likely he is having increase in allergen exposure which is exacerbating his symptoms. He
has most if not all of the clinical symptoms of Allergic Rhinoconjuntivitis.
2. Common Cold (B97.89) non-specified the cause of the common cold is generally caused
by rhinovirus. The symptoms of a cold can include: cough, sore throat, nasal drainage or
congestion, conjunctivitis, low grade temp and malaise (Allan & Arroll, 2014). While our
patient has many of the symptoms associated with a common cold he does not report
fatigue or malaise or have a low-grade temp. Although among his population the virus
could be spread more easily as he is in closer proximity to more individuals causing
further spread of the virus. At this time, I do not feel this is the case.
3. Acute Sinusitis (J01.90) Sinusitis can be viral or bacterial in nature. The causes of viral
sinusitis can include rhinovirus, influenza and parainfluenza virus. Bacterial sinusitis is
usually caused by Streptococcus Pneumoniae, Haemophilus Pneumonia or Moraxella
catarralis. Viral sinusitis is characterized by nasal congestion, rhinorrhea, headache, sore
throat, low grade fever, facial or dental pain. Viral sinusitis can result from having a cold.
Bacterial sinusitis can also develop from a viral sinusitis. Bacterial sinusitis signs and
symptoms increase dramatically with increased drainage of green/yellow nasal discharge
and will possibly require treatment with an antibiotic (Rosenfeld, Piccirillo,
Chandrasekhar, Brook, I., .et al.2015). Early sinusitis could possibly be a differential
although at this juncture he has only a few of the symptoms associated with and acute
sinusitis. If his allergic rhinitis is not controlled it could possibly progress to a sinusitis at
a later time.
Plan:
The patient is most likely suffering from a seasonal allergy exacerbation. Although the scenario
does not specifically state what season it is however the patient is out of his normal environment
and there may be more allergens than he is used to and may have now simply become an issue.
However, he is a college student and eye strain could be a consideration but he also has other
symptoms that do no associate with eye strain or overuse since he is probably using more
electronic devices while in school. Although it may feel he has a foreign body bilaterally his eye
exam did not show any debris on his eyes or under the lids with all three differential diagnoses
the eyes can be irritated with a feeling of a foreign body within the eye but it is probably from
the irritation itself and dryness. I would most likely resume his normal regime of his
RX: Loratadine 10( ten) mg (1) one tab by mouth daily
Disp:# 60 ( sixty) tabs
Sig: 1( one) tab daily by mouth especially during peak allergy season
This study source was downloaded by 100000836386117 from CourseHero.com on 03-08-2022 23:36:38 GMT -06:00
https://www.coursehero.com/file/32384110/Case-Study-week-3-part-1docx/
