NR 511 Differential Diagnosis and Primary Care Practicum (WEEK 3)

NR 511 Differential Diagnosis and Primary Care Practicum (WEEK 3)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: