NR511 Week 3 Case Study Part 1

Week 3 Case Study Part 1 Kayla Wilt NR 511 Differential Diagnosis and Primary Care Practicum Dr. Cole November 2019 Week 3 Case Study Part 1 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: 1. Allergic conjunctivitis – this is cause by an allergy induced inflammatory response. During this, allergen cooperate with IgE bound to induce mast cells yielding clinical ocular allergic expression. Activation of these mast cells causes enhanced levels of histamine, tryptase, prostaglandins and leukotrienes (La Rose, et al, 2013). This form of conjunctivitis occurs suddenly whenever an individual is exposed to a trigger. 2. Viral Conjunctivitis- This is the most common form of conjunctivitis. It usually occurs with/during a common cold or some other type of systemic viral infection. If viral conjunctivitis is localized, then it results from adenoviruses or enteroviruses (Solano, 2018). 3. Bacterial Conjunctivitis- This is the second most common form of conjunctivitis. In adults, it is mostly caused by the pathogen staphylococcal species, followed by Streptococcus pneumoniae and Haemophilus influenzae (Azari & Barney, 2013). Analyze: Differentials Ranked in Order 1. Symptoms of Allergic Conjunctivitis include redness, watery discharge, and itching of OU. Burning, sensitivity to light, and swelling of the eyelids are other symptoms that can occur. Individuals with this form of conjunctivitis have a history of allergies (La Rosa, et al, 2013). 2. Symptoms of Viral Conjunctivitis include starting in one eye then spreading to the other, watery discharge with mucous, crustiness around the eyelids, redness of the effected eye, photophobia, and swelling of preauricular lymph nodes (Solano, 2018).