Week 3 Case Study Part 1
.
Kayla Wilt
NR 511 Differential Diagnosis and Primary Care Practicum
Dr. Cole
November 2019
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, Week 3 Case Study Part 1
Subjective:
A 19-year-old male presents today with the CC of BL eye discomfort. The symptoms
started 2-3 days ago. The discomfort is present is BL eyes and is constant. He reports
the discomfort as being a 2/10. The patient states OU feel "gritty" with mild to moderate
amount of discomfort. He further describes the gritty sensation "like sand caught in your
eye." There are no aggravating or relieving factors. He has tried OTC Visine drops once
yesterday in which he reports it temporarily improved the redness, but the gritty
sensation, tearing and itching remained. He denies eye injury, trauma, visual changes
or dryness. He denies crusting of lids or mucoid or purulent drainage. He has seasonal
allergies that occur around spring. He takes Loratadine 10mg daily and fluticasone
nasal spray daily during the spring months when nasal allergies flare.
Physical exam:
VS Temp: 97.9 P: 68 RR:16 BP 120/75 Height 6’0 Weight 195lbs
Physical examination is essentially negative except for BL conjunctiva shows diffuse
redness and tearing and light sensitivity OU. The nasal turbinates are pale and boggy
with moderate swelling and clear drainage. No FBs, masses, or lesions noted. Visual
acuity intake with 20/20 OU. Fundiscopic examination is WNL. Examination of EAM is
WNL.
Differential Diagnosis:
This study source was downloaded by 100000842568006 from CourseHero.com on 07-11-2022 00:55:01 GMT -05:00
https://www.coursehero.com/file/53539612/NR511-Week-3-Case-Study-Part-1-Wilt-Kayladocx/
.
Kayla Wilt
NR 511 Differential Diagnosis and Primary Care Practicum
Dr. Cole
November 2019
This study source was downloaded by 100000842568006 from CourseHero.com on 07-11-2022 00:55:01 GMT -05:00
https://www.coursehero.com/file/53539612/NR511-Week-3-Case-Study-Part-1-Wilt-Kayladocx/
, Week 3 Case Study Part 1
Subjective:
A 19-year-old male presents today with the CC of BL eye discomfort. The symptoms
started 2-3 days ago. The discomfort is present is BL eyes and is constant. He reports
the discomfort as being a 2/10. The patient states OU feel "gritty" with mild to moderate
amount of discomfort. He further describes the gritty sensation "like sand caught in your
eye." There are no aggravating or relieving factors. He has tried OTC Visine drops once
yesterday in which he reports it temporarily improved the redness, but the gritty
sensation, tearing and itching remained. He denies eye injury, trauma, visual changes
or dryness. He denies crusting of lids or mucoid or purulent drainage. He has seasonal
allergies that occur around spring. He takes Loratadine 10mg daily and fluticasone
nasal spray daily during the spring months when nasal allergies flare.
Physical exam:
VS Temp: 97.9 P: 68 RR:16 BP 120/75 Height 6’0 Weight 195lbs
Physical examination is essentially negative except for BL conjunctiva shows diffuse
redness and tearing and light sensitivity OU. The nasal turbinates are pale and boggy
with moderate swelling and clear drainage. No FBs, masses, or lesions noted. Visual
acuity intake with 20/20 OU. Fundiscopic examination is WNL. Examination of EAM is
WNL.
Differential Diagnosis:
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https://www.coursehero.com/file/53539612/NR511-Week-3-Case-Study-Part-1-Wilt-Kayladocx/
