NR511 week 3 discussion 1 and 2 - 2018

Asked by sharpie
Dated: 14th Apr'18 07:31 AM
Bounty offered: $37.00

Week 3 discussion


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


2-3 days ago


Both eyes




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


Tried OTC visine drops yesterday which temporarily improved the redness but the gritty sensation, tearing and itching remained.


Level of discomfort is 2/10 on pain scale

Review of Systems (ROS)


Denies fever, chills, or recent illnesses


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.


-otalgia, -otorrhea


+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.


Denies ST and redness


Denies lymph node tenderness or swelling


Denies cough, SOB and wheezing


Denies chest pain



Loratadine 10mg daily and fluticasone nasal spray daily (only takes during the spring months when nasal allergies flare)


Seasonal allergic rhinitis with springtime triggers






Freshman student at the University of Awesome located in central Illinois. Home is in Phoenix.


Denies cigarettes +recreational marijuana use +drinks 3-6 beers per weekend


Adopted, does not know biological parents history

Physical exam reveals the following.

Physical Exam


Young adult male in NAD, alert and oriented, cooperative


Temp-97.9, P-68, R-16, BP 120/75, Height 6'0, Weight 195 pounds




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.


Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender.


Nares patent. Nasal turbinates are pale and boggy with mild to moderate swelling. Nasal drainage is clear.


Oropharynx moist, no lesions or exudate. Tonsils ¼ bilaterally. Teeth in good repair, no cavities noted.


Neck supple. No lymphadenopathy. Thyroid midline, small and firm without palpable masses.


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.


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:


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.

NR511 week 3 discussion 1 and 2 - 2018
Answered by sharpie
Expert Rating: 385 Ratings
Dated: 14th Apr'18 07:31 AM
5 words and 1 attachment(s).
Tutorial Rating: Not Rated
Sold 3 times.
(preview of the tutorial; some sections have been intentionally blurred)


NR511-week-3-discussion-1-and-2---2018.docx (85.69 KB)
Preview of NR511-week-3-discussion-1-and-2---2018.docx
question     Q   A?Many offices     list       Reply   CommentCollapse SubdiscussionL     Eyrone       Mar   at 7:45pmDr     course       the   provided for     Your       more   but I     the       Study   For the     writing       the   3 &     study,       format:   & strength     quantityDirectionsNumber       Atorvastatin   # 30Sig:     dailyRF:       0   30gmSig: apply     amount       twice   x 2     Reply       SubdiscussionL   BushL Eyrone     2018       8:30amDr   Patient education     for       conjunctivitis   protect and     reduce       and   the spread     conjunctivitis       Ophthalmology   2013) Along     on       and   measures, patient     include       medical   Patients who     pain,       loss   vision should     emergency       should   done for     a       herpes   and for     experience       improvement   one week,     moderate       recurrent   and corneal     &       steroids   an additional     vision       cataract   and increased     requiring       ophthalmologist   can also     of       corneal   and blindness,     underlying       with   herpes, fungus,     (Azari       As   we must     of       our   of practice     and       to   optimal patient     BushReferencesAmerican       [AAO]   Conjunctivitis PPP     Retrieved       org/preferred-practice-pattern/conjunctivitis-ppp--2013#HIGHLIGHTEDFINDINGSANDRECOMMENDATIONSFORCAREAzari,   A ,     N       A   review of     treatment       doi:10   2013 280318     to       OspinaMar   2018 Mar     1:09pmDiscussion       Part   Diagnosis: Allergic     regards       study,   primary diagnosis     given       Conjunctivitis   clinical signs     of       easily   and include     conjunctiva       chemosis   et al     The       of   pertinent positive     only       list   patient is     chemosis       Due   normal findings,     of       out   corneal abrasions     The       the   nose with     is       response   an allergen     The       by   of the     in       is   of the     triggers       following   is pollutants     (Leonardi,       2015)   patient exposes     smoke       recreational   of marijuana     10       diagnosis   Allergic Conjunctivitis     45       10mg   #30 Sig:     QD       HCLDisp   bottleSig: Place     in       0Fluticasone   Spray 50mcgDisp     One       nostril   0Intranasal corticosteroids     mainstay       allergic   (Sur &     In       to   coryza, I     to       to   with these     Flonase       reduce   inflammation to     mucosa       also   relief with     the       an   solution that     H1-antihistamine       According   Clinical Ophthalmology,     been       helps   itching throughout     of       is   affective in     (Mizoguetti,       2017)   use of     this       as   oral antihistamine,     also       help   particular patient     past       a   antihistamine, which     the       drowsy   with providing     Antihistmamines       the   of allergic     relieves       and   erythema (Stojkovic,     ,       testing   be performed     time       medications   prescribed Use     several       day   help with     Wash       placing   drops, and     touch       the   of the     smoking       smokers   the smoke     an       eyes   using the     sure       down   to toes)     medication       Avoid   and touching     Give       an   Follow Up:     in       symptoms   not improved     of       open   trauma, or     go       department   further evaluation     List:History       Drug   Allergic RhinitisSocial,     useReferencesLeonardi,       F   Castegnaro, A     D       Valerio,   , Mattana,     &       June   Allergic conjunctivitis:     study       Allergy,   1118-1125 doi:10     Mizoguchi,       M   & Ogino,     Efficacy       epinastine   0 1%     allergic       and   treatment Clinical     1747-1753       Stojkovic,   , Cekic,     Ristov,       M   Dukic, D     M       D   March 01)     Antihistamines       Naissensis,   doi:10 1515/afmnai-2015-0001     K       M   (2015, December     of       Family   92(11), 980-988     http://eds       chamberlainuniversity   oclc org/eds/pdfviewer/pdfviewer?vid=5&sid=b7528b9a-d2e1-4989-86e6-4f2aeeb7e742%40sessionmgr4007     to       Buechner-WiegandMar   2018 Mar     8:10pmJessica,       You   want to     evidence       your   prescriptions Good     follow       you   not list     Try       US,   practice journals     job!       Reply   CommentCollapse SubdiscussionJessica     17,       at   problem, and     So       to   a reference     Claritin       have   in for     Thanks       Reply   to CommentCollapse     SommerMar       13   11:48pmDr Buechner-Wiegand     My       for   patient is     ICD-10:       positives   the diagnosis     conjunctivitis       eye   History of     rhinitis       Bilateral   +redness, +tearing,     sensation       and   nasal turbinates     to       negatives   the diagnosis     conjunctivitis       trauma   eye injury-     of       mucoid/purulent   Negative for:     ST,       lymph   SOB, wheezing,     chest       drainage-   abnormalities in     head,       and   Denies fever,     recent       found   fundoscopic examination     managementI       1-2   to each     twice       for   eyesDiagnosis: allergic     (H10       6   bottle (refills     would       it   an antihistamine     cell       &   2016) Antihistamines     cell       mast   degranulation and     release       and   Azelastine has     time       should   used for     2       its   results (Marais,     combination       and   cell stabilizers,     proven       option   those suffering     conjunctivitis,       good-quality   evidence (Mousey     2016)       order   additional testing     diagnosis       &   (2016) states,     common       conjunctivitis   eye: itching,     lid       grey-white   mucous A     severe       a   itching pattern     indicates       is   by the     and       (McDonald   Sheppard, 2016)     him       his   due to     infection       Instruct   to keep     of       occur   are worse     him       allergy   (Marais, 2017)     seek       soon   possible if     any       his   and/or severe     He       to   ophthalmologist as     possible       any   discharge, crusting,     lymph       new   worsening eye     and       Treatment   would have     back       for   1-week follow-up     his       with   new medication,     refer       ophthalmologist   further testing     Also,       to   prescribed, as     McDonald       they   be prescribed     ophthalmologist       documented   side effects     to       also   considered, to     his       they   be avoided     Sheppard,       List   allergic rhinitis     triggersBilateral       itchingBilateral   tearing,Bilateral eye     eye       pale   boggy with     moderate       0-10   scale in     runny       nasal   References Marais,     The       Nursing   21(1), 16-21     https://chamberlainuniversity       ebscohost   aspx?direct=true&db=ccm&AN=123615940&site=ehost-live&scope=site McDonald,     ,       D   Making Allergic     a       41(10),   https://chamberlainuniversity idm     ebscohost       to   external site     an       A   , &     E       and   Cell Stabilizers     Allergic       Physician,   915-916 https://chamberlainuniversity     org/login?url=http://search       Reply   to CommentCollapse     MaynardMar       15   10:43pmRebecca, Good     your       amazing   such an     that       people   take such     amount       have   found that     a       medications   the market     same       the   faithful pharmaceuticals     best,       new   improved versions     unwanted       with   many times     The       medications   usually costly     always       our   The difference     6       is   a difference     family       income   rhinitis is     that       get   relief of     have       use   generations of     will       than   People who     symptoms       relief   those who     may       relief   patients achieve     relief       goal   2016) Ryan,     How       manage   allergic rhinitis     Community       Reply   to CommentCollapse     AdhikariMar       16   5:16amRebecca,You have     excellent       the   diagnosis as     the       mentioned   that steroids     be       I   found some     the       steroid   I would     share       and   (2013) stated     shouldn’t       that   only be     the       ophthalmologist   examined the     a       The   further explained     decreases       that   healing and     could       Mayhew,   American Academy     preferred       guidelines   also mentioned     who       need   measure IOP     pupillary       done   r/o any     cataract       Farkouh,   and Czejka     in       the   of ophthalmic     permissible       noninfectious   to decrease     cataract       treat   anterior and     uveitis       mentioned   some of     of       corticosteroid   cataract and     ptosis,       the   systemic toxicity     hyperglycemia       ,   Anuja References     of       panel   practice pattern     Conjunctivitis       aao   M &     (2013)       Primary   Provider, (4th     Retrieved       comFarkouh,   , Frigo,     &       Systemic   effects of     A       Ophthalmology,   2433–2441 doi:     S118409       CommentCollapse   Buechner-WiegandDana Buechner-WiegandMar     Mar       like   Azelastine, as     half       many   used for     Might       compresses   tylenol for     follow       When   your active     just       dx   rhinitis, acute     Would       thc   potential aggravator     this       use   the weekends     potential?       that   Professional Nursing     an       might   13 be     ICD10       I   forward to     Dr       to   SubdiscussionAnuja AdhikariAnuja     2018       7:32pmDr   and Class,What     primary       this   at this     the       diagnosis   pertinent positives     from       in   case studies     the       my   diagnosis for     is       As   stated in     posting       et   (2015) clinical     for       clinician   make clinical     AR       with   & P     allergic       or   symptoms are     as       rhinorrhea,   discoloration or     and       eye   patient does     history       and   all of     as       et   (2015) clinical     as       rhinorrhea,   discoloration or     and       eye   consistent with     symptoms       diagnosis   AR Pt’s     eye”       related   irritation of     well       is   In this     might       ask   patient if     constantly       air,   air heating     overuse       might   be the     to       In   seasonal conjunctivitis     American       PPP   (2013) includes     chemosis       Which   with patient     Pt’s       +   photosensitivity, which     more       conjunctivitis   than allergic     the       Allergic   J 30     H10       treatment   for this     diagnosis       Rhinitis   Below are     recommended       for   rhinitis:Topical Steroid:     will       medication   Flonase nasal     mcg/sprayDisp       two   in each     for       0Oral   (second generation     also       ’s   antihistamine Loratadine     mgDisp       Tab   0 Allergic     relief       allergic   topical medication     by       Ophthalmology   guidelines:Second-generation topical     antagonistsLastacaft       Disp   1Sig: 1     both       a   for 7     Education:To       eye   below are     the       allergic   following American     Ophthalmology       cool   in both     times       as   clothes washing     before       if   Referral and     the       7   the clinic     purulent       nose   eyes, SOB,     or       In   case Pt     having       Pt   also have     allergy       unaware   in this     so       referring   patient to     (skin       only   in f/u     doesn’t       patient   comes to     with       As   by Seidman     (2015)       rhinitis   uncertain of     allergen       is   American Academy     PPP       recommends   allergist or     patients       that   adequately controlled     medication       Active   list:Eyes: Bilateral     +redness,       FB   Level of     2/10       Sensation   eyes "like     in       +   Nose: Occasional     with       AnujaReferences   Academy of     Disease       pattern   (2013) Conjunctivitis     https://www       D   Gurgel, R     Lin,       Schwartz,   R ,     M       R   Nnacheta, L     Clinical       Rhinitis   Academy of     Neck       S1-S43   10 1177/0194599814561600     to       Buechner-WiegandMar   2018 Mar     6:52pm       have   evidence based     after       use   for dosing     active       be   acute atopic     rhinitis       nose),   medical terminology,     you       thc/weekend   as well     opportunity       prevention?   you are     call       conjunctivitis,   your icd     I       be   acute as     a       is   in Illinois     Arizona       forward   your responses,     full       Dr   by Dana     Mar       Reply   to CommentCollapse     CastellanosMar       17   1:22pmAnuja,I enjoyed     post       you,   on "American     Ophthalmology       Second-generation   histamine H1-receptor     be       used   this case     these       also   some (OTC)     more       cost   -Elestat (Epinastine     (OTC)       Sig:   drops twice     needed       Loratadine   -Nasacort (Triamcinolone     1       sprays   nostril daily     Epocrates       10   Dispense: 30     Take       Refill:   Epocrates Loratadine     drops       for   with allergic     patient       student   the University     located       It   to be     allergy       occur   the fall     this       the   on 10/20/2017     already       mg   as needed     Zyrtec       treatment   relieving allergic     and       allergic   (SAC) can     allergic       patient   nasal symptoms,     why       to   these symptoms     I       allergy   to determine     triggers       developing   later in     outgrow       testing   be performed     specific       (or   test) or     prick       2017)   suggest using     treatment       Sinus   kits or     are       treatment   rhinitis (Doyle,     on       ,   should also     additional       patient   order for     help       with   allergens for     exposure,       exposure   pets Some     to       of   Asthma, and     2014)       Avoid   window fans     home,       are   stay indoors     as       or   when outdoors     pollen       when   the leaves     the       medicine   reduce symptoms     a       hanging   outside to     this       to   try not     eyes,       them   exacerbate symptoms     Keep       air-conditioning   in car     and       clean,   floors with     or       than   or dry-dusting,     “mite-proofs”       comforters,   and pillows     in       the   in the     30       to   exposure to     keep       bathrooms   In damp     a       any   mold Exposure     After       wash   and wash     exposure       a   house, if     central       or   close the     to       carpet   linoleum, tile,     flooring,       animals   you are     if       home   keep air     your       when   sleep I     a       allergist   to follow-up     the       testing   complete An     immunology       on   patients who     tried       without   and want     treatment       Portnoy,   Lang, 2017)     of       Immunology   (2014) Allergic     from       to   external site     an       to   external site     an       M   (2017) Allergic     Nursing,       fromhttps://chamberlainuniversity   oclc org/login?url=http://search     aspx?direct=true&db=ccm&AN=122991314&site=eds-live&scope=site       external   )Links to     site       external   )Links to     site       Retrieved   https://online epocrates     to       )Links   an external     to       )Links   an external     Loratadine       L   Diagnosing a     An       infection?   Nursing Today,     Wallace,       Dykewicz,   S ,     ,       ,   Lang, D     Pharmacologictreatment       rhinitis:   of guidance     2017       onpractice   Annals of     167(12),       Reply   to CommentCollapse     AdhikariMar       18   3:30pmDr Dana,     for       giving   some pointers     need       value   patient One     that       doing   lot more     practical       10   will change     diagnosis       conjunctivitis   H10 11     mentions       second   thirty major     cities       and   are regional     the       Arizona   Illinois Pt     unknown       that   patient needs     mindful       will   educating the     be       and   a log     a       that   be used     rule       or   causes for     Below       the   education I     providing       for   and recreational     Patient       that   marijuana is     in       Arizona)   there could     legal       the   is 19     it       in   states where     recreational       for   under the     21       Marijuana   extremely addictive     one       of   performance in     College       impairs   and motor     doubles