31 May A 19-year-old male freshman college student presents to the student health center today with complaints of bilateral eye discomfort
A 19-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 and fluticasone nasal spray 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. 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.
DQ2
Now, assume that any procedures and/or testing which were performed are NORMAL.
What is your primary (one) diagnosis for this patient at this time? (support the decision for your diagnosis with pertinent positives and negatives from the case)
Identify the corresponding ICD-10 code.
Provide a treatment plan for this patient’s primary diagnosis which includes:
Medication*
Any additional testing necessary for this particular diagnosis*
Patient education
Referral and follow-up to the treatment plan
Provide an active problem list for this patient based on the information given in the case.
*If part of the plan does not warrant an action, you must explain why. ALL medication and testing decisions (or decisions not to treat with medication or additional testing) MUST be supported with an evidence-based medicine (EBM) argument. Over-the-counter (OTC) and RXs must be written in full as if handing a script to the patient in the office.
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