September 28, 2025 Claire B 0 Comments

Week 3
discussion

DQ1

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

Characteristics

Both eyes feel “gritty” with mild
to moderate amount of discomfort. Further describes the gritty sensation
“like sand caught in your eye”

Aggravating factors

None identified

Relieving factors

None identified

Treatments

Tried OTC visine drops yesterday which temporarily improved
the redness but the gritty sensation, tearing and itching remained.

Severity

Level of discomfort is 2/10 on pain scale

Review of Systems (ROS)

Constitutional

Denies fever, chills, or recent illnesses

Eyes

Denies contact lenses or glasses, has never
experienced these symptoms previously. Last eye exam was “a few years
ago”. Denies recent trauma or eye injury. Denies crusting of lids or
mucoid or purulent drainage. Bilateral symptoms of +redness, +itching,
+tearing + FB sensation.

Ears

-otalgia, -otorrhea

Nose

+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 loratadine and
fluticasone nasal spray taken during peak season.

Throat

Denies ST and redness

Neck

Denies lymph node tenderness or swelling

Chest

Denies cough, SOB and wheezing

Heart

Denies chest pain

History

Medications

Loratadine 10mg daily and fluticasone nasal
spray daily (only takes during the spring months when nasal allergies flare)

PMH

Seasonal allergic rhinitis with springtime
triggers

PSH

None

Allergies

None

Social

Freshman student at the University of
Awesome located in central Illinois. Home is in 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. + photosensitivity. No crusting, lesions or masses on lids
noted. Bilateral conjunctiva with diffuse redness and tearing but no mucoid
or purulent drainage noted. No visible FBs under lids or on cornea to gross
examination.

Fundiscopic examination: 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 gray and intact with
light reflex noted. Pinna and tragus nontender.

Nose

Nares patent. Nasal turbinates are pale and
boggy with mild to moderate swelling. Nasal drainage is clear.

Throat

Oropharynx moist, no lesions or exudate.
Tonsils ΒΌ bilaterally. Teeth in good repair, no cavities noted.

Neck

Neck supple. No lymphadenopathy. Thyroid
midline, small and firm without palpable masses.

Cardiopulmonary

Heart S1 and S2 noted, no murmurs, noted.
Lungs clear to auscultation bilaterally. Respirations unlabored.

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.

Provide a differential diagnosis (minimum of 3) which might
explain the patient’s chief complaint along with a brief statement of
pathophysiology for each.

Analyze the differential by using the pertinent findings
from the history and physical to argue for or against a diagnosis. Rank the
differential in order of most likely to least likely.

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.

DQ2

Now, assume that any procedures and/or testing which were
performed are NORMAL.

What is your primary (one) diagnosis for this patient at
this time? (support the decision for your diagnosis with pertinent positives
and negatives from the case)

Identify the corresponding ICD-10 code.

Provide a treatment plan for this patient’s primary
diagnosis which includes:

Medication*

Any additional testing necessary for this particular
diagnosis*

Patient education

Referral and follow-up to the treatment plan

Provide an active problem list for this patient based on the
information given in the case.

*If part of the plan does not warrant an action, you must
explain why. ALL medication and testing decisions (or decisions not to treat
with medication or additional testing) MUST be supported with an evidence-based
medicine (EBM) argument. Over-the-counter (OTC) and RXs must be written in full
as if handing a script to the patient in the office.

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