NR 511 WEEK 3 CASE STUDY DISCUSSION PART 1 WITH ANSWERS
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Course
NR 511
Institution
Chamberlain College Of Nursing
NR 511 WEEK 3 CASE STUDY ANSWERS DISCUSSION PART 1 WITH
NR511 Week 3 Case Study Part 1
CC: “eye discomfort” History of present illness:
This patient is a 19-year-old male who presents to the student health center today with complaints of bilateral mild to moderate eye discomfort describe a...
nr 511 week 3 case study answers discussion part 1 with nr511 week 3 case study part 1 cc “eye discomfort” history of present illness this patient is a 19 year old male who presents to the student
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NR 511
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NR 511 WEEK 3 CASE STUDY DISCUSSION PART 1 WITH
ANSWERS
NR511 Week 3 Case Study Part 1
CC: “eye discomfort”
History of present
illness:
This patient is a 19-year-old male who presents to the student health center today
with complaints of bilateral mild to moderate eye discomfort describe as “gritty”
and “like sand in my eye” with some tearing and itching which started 2-3 days
ago. He rates his discomfort a 2/10 and constant. There is no aggravating or
relieving factors noted. He has reported using OTC Visine which temporarily
resolved the redness only.
ROS:
Constitutional: Negative. Denies fever, chills, or recent illnesses
HEENT: Negative. Denies the use of contact or glasses. Denies any eye injuries,
trauma, or visual changes or dryness. Denies crusting of the eye lids, mucoid, or
purulent drainage. The patient reported having redness, itching, tearing and FB
sensation. Patient reported his last eye exam was a “few years ago”. He denies
having any ear pain but reports having an occasional runny nose with intermittent
nasal congestion, denies sneezing. He has a past medical hx of seasonal nasal
allergies that is aggravated in the spring and controlled with the use of loratadine
10mg and fluticasone nasal spray. He denies chest pain, cough, SOB, wheezing,
lymph node tenderness, swelling, redness, or ST.
PSH: Denies having a
PSH Allergies: Denies
allergies
Social Hx / habits: He currently lives in Phoenix, and he is a current freshman student
at the University of Awesome located in central Illinois. The patient denies the use of
cigarettes, but to smoking marijuana and drinks between 3-6 beers on the weekend.
Physical Exam:
Constitutional: Young adult male in NAD, alert, oriented and
cooperative VS: Temp–97.9, P–68, RR-16, BP 120/75, Hgt, 6’0”,
Wgt 195lbs
Head: Normocephalic
Visual Acuity uncorrected is 20/20, sclera is white bilaterally. No evidence of
crusting, lesions, or masses on lids noted. There is slight photophobia noted
bilaterally. Conjunctiva with diffused redness and tearing bilaterally without mucoid
or purulent drainage noted. Further examination of bilateral eyes is negative for FBs
beneath the eye lids or on the cornea to gross examination. Examination of the
, fundus noted WNL. Tympanic membrane intact no tenderness noted.
Inspection of the nose revealed pale and boggy turbinates with mild to moderate
swelling, clear nasal drainage and patent nares. Thyroid is midline, no palpable
masses. Lung sounds clear with auscultation and S1 and S2 noted and no M/G/R.
Differential Diagnoses
Allergic rhinitis is characterized as one of the most common incurable diseases
affecting adults, considered the most common incurable diseases in children, and
also considered the fifth most common incurable diseases in the United States
(Siedman, Gurgel, & Lin, 2015).
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