NR 511 WEEK 3 CASE STUDY DISCUSSION PART
1 WITH ANSWERS
History and Physical:
A 19-year-old male freshman college student presents to the student health center
today with complaints of bilateral eye discomfort. Beginning two to three days ago the
patient has been having bilateral constant pain in which he describes to be at a 2/10
pain scale. Patient states that both eyes feel “gritty” with a mild amount of discomfort
and states that he feels “like sand caught in your eye.” There are no aggravating factors
or relieving factors noted from the patient and has used OTC visine drops yesterday
only. This helped his redness but did not help with the gritty, itching and tearing feeling.
Upon further assessment of ROS patient has denied fever, chills or recent illness.
Denies ST and redness, denies lymph node tenderness or swelling, denies cough, SOB
and wheezing, denies chest pain. Patient does not use lenses or glasses and this is his
first experience of this instance. Last eye exam was a “few years ago.” Patient denies
any eye trauma or visual changes or dryness. Denies crusting of lids, mucoid or
purulent drainage. Positive for redness, itching, tearing, and foreign body sensation.
Denies ear pain, otalgia, otorrhea. Positive for complaints of runny nose with the
intermittent nasal congestion, denies sneezing. He does have seasonal allergies but
well controlled on loratadine and fluticasone nasal spray taken during peak season.
Patient is not currently taking these at this moment.
Previous medications include Loratadine 10mg daily and fluticasone nasal spray daily
(only takes during the spring months when nasal allergies flare).
No allergies and 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.
Vitals: Temp-97.9, P-68, R-16, BP 120/75, Height 6'0, Weight 195 pounds
Physical exam is mostly negative, no acute distress, cooperative, visual acuity 20/20.
Fundiscopic examination is within normal limits. Positive findings are nasal turbinates
are pale and boggy with mild to moderate swelling. Nasal drainage clear, tonsils +1
bilaterally. Cardiopulmonary exam negative with no rubs, murmurs or gallops.
Respirations unlabored.
Differential Diagnosis:
Allergic Conjunctivitis: The patient has a history of seasonal allergies and is exposed to
marijuana smoke which may be the main reason for his exacerbation of symptoms.
Allergic conjunctivitis fits the patients symptoms more so than the other differentials I
will have in my assessment/plan. Allergic conjunctivitis is characterized y purpuritis,
redness, tearing, burning and photophobia which is what our patient is having minus the
photophobia. “Allergic conjunctivitis is caused by an IgE-mediated mechanism or
1 WITH ANSWERS
History and Physical:
A 19-year-old male freshman college student presents to the student health center
today with complaints of bilateral eye discomfort. Beginning two to three days ago the
patient has been having bilateral constant pain in which he describes to be at a 2/10
pain scale. Patient states that both eyes feel “gritty” with a mild amount of discomfort
and states that he feels “like sand caught in your eye.” There are no aggravating factors
or relieving factors noted from the patient and has used OTC visine drops yesterday
only. This helped his redness but did not help with the gritty, itching and tearing feeling.
Upon further assessment of ROS patient has denied fever, chills or recent illness.
Denies ST and redness, denies lymph node tenderness or swelling, denies cough, SOB
and wheezing, denies chest pain. Patient does not use lenses or glasses and this is his
first experience of this instance. Last eye exam was a “few years ago.” Patient denies
any eye trauma or visual changes or dryness. Denies crusting of lids, mucoid or
purulent drainage. Positive for redness, itching, tearing, and foreign body sensation.
Denies ear pain, otalgia, otorrhea. Positive for complaints of runny nose with the
intermittent nasal congestion, denies sneezing. He does have seasonal allergies but
well controlled on loratadine and fluticasone nasal spray taken during peak season.
Patient is not currently taking these at this moment.
Previous medications include Loratadine 10mg daily and fluticasone nasal spray daily
(only takes during the spring months when nasal allergies flare).
No allergies and 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.
Vitals: Temp-97.9, P-68, R-16, BP 120/75, Height 6'0, Weight 195 pounds
Physical exam is mostly negative, no acute distress, cooperative, visual acuity 20/20.
Fundiscopic examination is within normal limits. Positive findings are nasal turbinates
are pale and boggy with mild to moderate swelling. Nasal drainage clear, tonsils +1
bilaterally. Cardiopulmonary exam negative with no rubs, murmurs or gallops.
Respirations unlabored.
Differential Diagnosis:
Allergic Conjunctivitis: The patient has a history of seasonal allergies and is exposed to
marijuana smoke which may be the main reason for his exacerbation of symptoms.
Allergic conjunctivitis fits the patients symptoms more so than the other differentials I
will have in my assessment/plan. Allergic conjunctivitis is characterized y purpuritis,
redness, tearing, burning and photophobia which is what our patient is having minus the
photophobia. “Allergic conjunctivitis is caused by an IgE-mediated mechanism or
