NR511 Wk 3 Case Study Part 1

NR511 Wk 3 Case Study Part 1J.T. is a 19yo male c/o bilat eye discomfort x2-3 days. Pt states “both eyes feel gritty like sand caught in your eye.” Reports mild-moderate discomfort that is constant. Nothing relieves, nothing aggravates. Reports trying OTC Visine drops yesterday x1, relieved redness temporarily, but not gritty sensation, tearing, or itching. Current pain level 2/10. ROS negative for significant findings with the exception of redness, itching, tearing, FB sensation to bilat eyes, and occasional rhinorrhea w/intermittent nasal congestion. Takes loratadine 10mg daily and fluticasone nasal spray daily for seasonal nasal allergies during peak season; not taking at this time, states meds control symptoms well when needed. No significant PMH with exception of above-mentioned seasonal allergic rhinitis. Currently freshman at University of Awesome. Denies cigarette use, reports recreational THC use, drinks 3-6 beers/weekend. Unknown FHx due to being adopted. Physical exam significant for slight photophobia bilat, and diffuse redness and tearing to bilat conjunctiva without purulent drainage. Eyes, including fundoscopic exam, otherwise negative for significant findings. Nasal turbinates pale, boggy w/mild-moderate swelling and clear drainage, otherwise negative for significant findings. Tonsils ¼ bilat, no exudate/erythema. Physical exam negative otherwise for any significant findings.