NR511 week 3 -Discussion 1 and 2 - April 2018

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dq 1

Week 3: Discussion Part One

22 unread replies.2525 replies.

Date of visit: October 20, 2017

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.



dq 2

Week 3: Discussion Part Two

11 unread reply.2525 replies.

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.

NR511 week 3 -Discussion 1 and 2 - April 2018
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L     I       is   common in     While       treated   antibiotics the     viral       A   of viruses     responsible       but   is by     most       my   Herpes simplex     is       Viral   is highly     for       onset   long as     are       should   touching their     hands,       napkins,   cases, and     among       transmission   occur through     of       the   hands or     with       droplets,   or contaminated     (Aoki       2014)   infection process     spontaneously       Regarding   irritation relief,     that       be   to soothe     Randomized       by   et al     found       dexamethasone   1%/povidone-iodine 0     drops       day   reduce the     disease       tears   0 1%     4%       of   and an     This       short-term   and in     are       this   including: allergic     history       disease,   ocular disease     a       surgery   sciencedirect com/journal/japanese-journal-of-ophthalmology/vol/42/issue/1Links     external       com/doi/abs/10   2014 964419Links     external       to   SubdiscussionDana Buechner-WiegandDana     2018       2:13pmYour   to your     of       the   If you     patient       it   out of     of       you   on page     your       will   a referral     immediately       you   know your     this       them!   your reference     a       are   wanting you     use       references,   with family     are       make   out of     you       a   not to     type       a   it is     know       and   NOT treat     to       refer   you are     land       courtroom   all of     to       references   want to     learn       care   that is     liability       that   is where     FNP       will   based upon     Edited       on   16 at     Reply       CastellanosKaly   20, 2018     at       FNP   we will     in       this   why we     for       that   the reason     are       teach   and give     that       to   not to     feel       way   are not     experienced       yet   , I     have       and   hope I     more       in   future discussions     want       it   under the     on       not   or wrongs     is       discussion   why can     give       of   As always     the       to   SubdiscussionDana Buechner-WiegandDana     2018       6:34pmEyrone,You   to include     pertinent       with   differential In     what       and   that are     lead       that   is allergic     viral       or   eye Its     you       for   (your patients     Your       Your   analysis is     are       track   your analysis     evidence       will   you again     DanaEdited       on   12 at     Reply       Eyrone   Eyrone BushMar     Mar       Dana,I   not sure     organize       and   so I     critical       the   positives and     stated       the   Differential Anyalysis     ThinkingAllergic       be   top differential     on       bilateral   involvement, acute     and       redness,   FB sensation,     The       photosensitivity,   redness and     conjunctiva,       turbinates,   swelling, and     discharge,       allergic   (National Guideline     2015)       sensation   also be     on       (dust,   smoke) and     of       Blaiss,   Further supporting     is       of   allergies In     of       pain,   or corrective     the       most   Pertinent positives:     involvement,       eye   itching, FB     tearing       exam:   diffuse redness     of       nasal   nasal swelling,     nasal       an   response (National     [NGC],       No   eye pain,     corrective       fever,   illness, or     purulent       changes   FB No     No       and   sensation may     present       environmental   (dust, pollen,     the       (Lan   Blaiss, 2013)     this       patient’s   of seasonal     the       or   pain, injury,     lens       diagnosis   most likely     (VC)       supported   symptoms of     involvement,       and   visual changes     very       due   the lack     on       of   fever, and     with       (Azari   Barney, 2013)     denies       only   allergy symptoms     bilateral       photosensitivity,   conjunctival redness     Pertinent       chills,   recent illness     changes,       crusting,   lesions Ears/Throat/neck     erythema,       No   Lungs CTA,     or       (BC)   the unlikely     patient       can   with acute     discomfort,       to   conjunctivitis, it     accompanied       drainage   crusting of     which       not   BC does     present       the   and can     one       His   would be     he       had   injury to     or       to   else with     (Azari       Pertinent   bilateral eye     tearing,       sensation   negatives: No     recent       for   drainage, crusting,     and       No   and pain     Dry       some   the complaints     patient       grittiness,   stinging, and     tearing       but   has no     conditions       factors   the disease     with       of   If symptoms     or       to   treatment regimen     conjunctivitis,       be   to evaluate     syndrome       onset   symptoms Eyes     photosensitivity,       and   Seasonal allergies     Absence       exam   visual changes     without       medical   Never had     before       to   SubdiscussionRebecca SommerRebecca     2018       2:31pmDr   and class,The     a       H&P   the above     year       college   presents to     with       pain   0-10 scale)     bilateral       a   of seasonal     with       denies   and NKA     started       which   states is     feeling       constant   describes the     though       caught   his eyes     identify       relieving   He tried     eye       relived   redness but     help       tearing   itching Upon     symptoms,       symptoms   infection or     Patient       contact   or glasses     not       exam   a few     denies       eye   crusting of     or       eyes   +itching, +tearing     sensation       otorrhea,   swollen or     nodes,       chest   or present     He       uses   marijuana and     3-6       He   not know     family       is   Upon physical     findings       bilateral   diffuse redness     to       turbinates   pale and     mild       but   patent His     is       are   abnormalities in     head,       and   Differential diagnoses     patient       of   Allergic conjunctivitisAllergic     a       presenting   inflammation from     allergy       produced   response to     allergen       (Marais,   The allergic     mast       the   mast cells     the       findings   the eye     discomfort,       or   vision (Marais,     conjunctivitis       by   of the     triggers,       exposure   allergens, genetic     immunological       Allergic   can be     two       non-severe   allergic conjunctivitis     atopic       conjunctivitis   vernal keratoconjunctivitis     Non-severe       perennial   conjunctivitis, seasonal     and       (Marais,   Non-severe conjunctivitis     without       be   by the     individual       mast   stabilizers or     2017)       requires   and is     be       ophthalmologist   2017) Viral     conjuntivitis       by   virus entering     swelling       the   According to     Barney       80%   acute cases     are       most   virus being     (in       of   Viral conjunctivitis     when       viral   is acquired,     a       droplet   (such as     coughing)       is   to limit     developing       can   be spread     mucous       individual   if the     in       lungs,   or nasal     virus       the   (Azari, &     Ocular       examples   metal, glass     can       swelling   the cornea     or       of   eye The     the       ocular   body is     the       and   of momentum     impact       of   (Bhalerao, Singh,     Rathi,       not   an ocular     could       so   to ophthalmologist     if       the   body out     spot       area   poses a     the       al   2017) Adult     Malamos       states   adult inclusion     is       Chlamydia   serotypes D     (which       bacterial   Oftentimes one     chlamydia       they   disease because     can       a   period of     to       al   2001) Chlamydia     STD       through   sex (vaginal,     oral       contaminated   enters the     from       Order   most to     differential       1)   conjunctivitisThis would     first       he   has a     allergies,       feeling   constant #3)     is       over   counter vision     his       he   no signs     of       infection   tearing, itching,     photosensitivity,       redness   bilateral eyes     denies       his   turbinates are     boggy       moderate   with clear     and       crusting   his lids     drainage       conjunctival   are present     of       allergic   and up     of       with   and persistent     episodes       of   symptoms can     by       Viral   conjunctivas is     differential       over-the-counter   drops helped     eyes       not   away the     tearing       tearing,   watery eyes,     sensation       his   eyes could     to       infection   & Barney,     his       pale   boggy with     moderate       nasal   which could     of       The   he does     crusting       or   drainage and     denies       a   infection does     chances       viral   (why it     2)       conjunctivas   to his     not       sexual   ruling out     a       is   AIC could     itching,       FB   and redness     bilateral       to   fact he     trauma       turbinates   pale and     mild       with   nasal drainage     indicative       another   causing his     that       of   as a     that       or   infection and     crusting       lids   mucoid/purulent drainage     foreign       states   he feels     he       his   I would     look       with   ophthalmoscope and     that       something   in his     could       redness   would not     his       pale   boggy with     moderate       nasal   TestingIt is     gather       on   patient (Malamos     2013)       currently   active, I     a       test   to rule     I       Polymerase   Reaction Test     has       compared   any other     for       al,   In up     of       AIC,   chlamydia infection     present       assess   for signs     of       genital   I would     to       eye   any foreign     with       &   2013) If     eye       panel   back negative     place       for   conjunctivitis including:     cell       Allergic   can be     on       history   physical assessment     of       itchiness,   redness, eye     eye       or   infection and     of       mucoid/purulent   (Marais, 2017)     the       laboratory   for the     allergic       of   tests to     causes       would   him come     my       follow   in 1     see       improved   subsided If     would       to   ophthalmologist for     and       A   & Barney,     (2013)       Review   Diagnosis and     The       American   Association, 310(16),     org/10       from:   ncbi nlm     to       Bhalerao,   A ,     ,       ,   Rathi, V     sting       bee:   unusual subconjunctival     Indian       65(11),   doi:10 4103/ijo     https://chamberlainuniversity       ebscohost   aspx?direct=true&db=ccm&AN=126239698&site=ehost-live&scope=siteLinks to     site       Georgalas,   , Rallis,     Andrianopoulos,       P   Georgopoulos, G     Markomichelakis,       Evaluation   Direct Immunofluorescence     Cytological       to   Chain Reaction     Swabs       Adult   Conjunctivitis Seminars     28(4),       2012   from https://chamberlainuniversity     org/login?url=http://search       to   external site     (2017)       Professional