- 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.
Date of visit: October 15, 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|
|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 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.|
|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|
|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|
|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|
This is a 19-year-old male that is a freshman at the University of Awesome who is in NAD, alert and oriented, and cooperative. He has a past medical history of seasonal allergic rhinitis which he takes loratadine 10 mg daily and fluticasone spray which he only takes during springtime flare-ups. He denies smoking cigarettes but does use recreational marijuana and drinks 3-6 beers on the weekends. He is adopted and his FH is unknown. Today he presents with a CC of bilateral eye discomfort. He denies wearing contact lenses. The onset of symptoms began 2-3 days ago which he describes as a mild to moderate discomfort and constant “gritty” or “like sand caught in your eye” sensation. There are no aggravating or relieving factors. He has tried OTC Visine drops with temporary relief of redness but not the tearing, gritty sensation, or itching. He states his level of discomfort is 2/10 on a pain scale….Kindly click the purchase icon to purchase the full solution at $10