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 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. 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 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. Tests Done: Considering the nature of the patient, additional tests such as those for meningitis are required. This is because the infective conjunctivitis has been closely associated with the spread of other infections bacterial and viral to other body regions. It is critical to note that it is too early to rule out a bacterial or viral secondary infection to the infective conjunctivitis. It is therefore important that the test is done to be sure that the patient is not suffering from meningitis or any other infection. (support the decision for your diagnosis with pertinent positives and negatives from the case) 2. 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. 5. Are there any changes that you would also make to this patients overall treatment plan at this time? Must provide an EBM argument for each treatment or testing decision. 6. Provide an appropriate F/U plan.
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