Week 3: Discussion Part One
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Date of visit: October 20, 2017
A 25 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 (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 ¼
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. IF you ordered a test or performed a procedure,
identify the corresponding Current Procedural Terminology (CPT) code(s). If not
applicable, list n/a. 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.
