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NR511 Week 6: Clinical Case Study Part One Discussion - A 56-year-old Caucasian female presents to the office today with complaints of fatigue. $10.99   Add to cart

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NR511 Week 6: Clinical Case Study Part One Discussion - A 56-year-old Caucasian female presents to the office today with complaints of fatigue.

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(Answered) NR511 Week 6: Clinical Case Study Part One Discussion Week 6: Clinical Case Study Part One Discussion No unread replies.No replies. Purpose Problem-based learning is a methodology designed to help students develop the reasoning process used in clinical practice through problem solving...

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  • February 9, 2022
  • 8
  • 2021/2022
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Week 3: Clinical Case Study Part One Discussion
No unread replies. No 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

Both eyes feel "gritty" with mild to moderate amount of discomfort. Further describes
Characteristics
the gritty sensation "like sand caught in your eye"

Aggravating
None identified
factors

Relieving
None identified
factors

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



Severity Level of discomfort is 2/10 on pain scale

Review of Systems (ROS)

Denies fever, chills, or recent illnesses
Constitutional


Denies contact lenses or glasses, has never experienced these symptoms
previously. Last eye exam was "a few years ago". Denies eye injury, trauma, visual
Eyes
changes or dryness. Denies crusting of lids or mucoid or purulent drainage. Bilateral
symptoms of +redness, +itching, +tearing + FB sensation.

Ears -otalgia, -otorrhea

This study source was downloaded by 100000770861734 from CourseHero.com on 02-09-2022 11:53:36 GMT -06:00


https://www.coursehero.com/file/39920171/Case-study-wk-3-A-and-3B-finaldocx/

, +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
Nose
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

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

PMH Seasonal allergic rhinitis with springtime triggers

PSH None

Allergies None

Freshman student at the University of Awesome located in central Illinois. Home is in
Social
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
This study source was downloaded by 100000770861734 from CourseHero.com on 02-09-2022 11:53:36 GMT -06:00


https://www.coursehero.com/file/39920171/Case-study-wk-3-A-and-3B-finaldocx/

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