Part 2: 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. 3. Provide a treatment plan for this patient's primary diagnosis which includes:
Medication. Any additional testing necessary for this particular diagnosis. Patient education Referral 4. Provide an active problem list for this patient based on the information given in the case. - Are there any changes that you would also make to this patient's overall treatment plan at this time? Must provide an EBM argument for each treatment or testing decision.
- Provide an appropriate F/U plan.
If part of the plan does not warrant an action, you must explain vehy. ALL medication and testing decisions (or decisions not to treat with medication or additional testing) MUST b pported 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.
HPI Summary The 19-year-old male reports feeling a gritty eye sensation. This feeling makes him feel like he has particles of sand stuck in his eyes. Ideally, he reports feeling discomfort, which is characteristic of itching, redness, and tearing. The 19yo male I presented in the case has a vital signs capacity of 97.9 worth of temperature, a pulse rate of 68, RR of 16, BP 120/76, and weight of 195 oz. The patient further depicts a bilateral eye discomfort for all eyes. Ideally, the presentation notes a 2 out of ten pain scale, lack of HPI, denies fever and chills, SOB, and chest pain. He further presents symptoms synonymous with running nose and nasal congestion. Differential Diagnosis and Ranking There are three diagnoses associated with this condition as follows: Conjunctivitis The condition is the inflammation of the eyelid's membrane lining. Conjunctivitis is characteristic of red itchy eye and could be due to a bacterial or viral infection (Webmd, 2018). This condition should rank as number one due to its bilateral presence in the patient's CC as seen with "gritting" and "redding' Blepharitis Blapharitis is a form of inflammation characterized by scaling, eye reddening. and crusting. The condition causes itching, grainy sensation, and burning in one's eyes. This condition ranks second as promoted by tearing and reddening of the patient's eyes. However, the patient's condition lacks lesions, masses, and crushing, which disqualify its diagnostics (Mayo Clinic, 2019). Dry eye syndrome The condition could also be as a result of insufficient eye lubrication. The clinical presentation that affirms to dry eye syndrome include reduced tearing and visible discomfort to the conjunctiva and cornea. This condition ranks last for its failure to approve tearing and hemorrhage for appropriate functionality (Mayo Clinic, 2019). Additional Tests The series' producers look into activities leading to its demise. The activity in question looks into conjunctivitis as the primary condition. However, it would be impossible to determine the exact form of conjunctivitis ailing this patient. That said, there is a need to test the patient's mucoid discharge to ascertain any forms of bacterial infection affecting the patient. This way, they should be able to reach the right amount of diagnosis available for treatment (Webmd, 2018).
References Mayo Clinic. (2019). Blepharitis. Retrieved from Mayo Clinic: https://www.mayoclinic.org/diseases-conditionsiblepharitisisymptoms-causes/syc-20370141 Mayo Clinic. (2019). Dry Eyes. Retrieved from tvlayo Clinic: https://wwamayoclinic.orgicliseases-conditions/dry-eyes/symptoms-causesisyc-20371863 Webmd. (2018). Conjunctivitis (Pinkeye). Retrieved from Webmd: https://www.webmd.com/eye-healthfeye-health-conjunctivitis.
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 ■ 11,0111 eye"
Aggravating factors None identified Relieving factors None identified Treatments
Tried OTC visine drops once 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 eye injury, trauma, visual changes or dryness. 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 (he is not taking either right now).
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. Slight light sensitivity noted bilaterally. 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. tvlacula has even color.
Ears
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 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 (FIR,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. Ail 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.
Sample Solution