NR511: DIFFERENTIAL DIAGNOSIS AND PRIMARY CARE

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NR511: Differential Diagnosis and Primary Care

NR511: Differential Diagnosis and Primary Care
NR511: Differential Diagnosis and Primary Care
Week 3: Discussion Part One
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Date of visit: October 20, 2017
A 25 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
ORDER A PLAGIARISM-FREE PAPER
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 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 recent trauma or eye injury. 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.
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 (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. + photosensitivity. 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. NR511: Differential Diagnosis and Primary Care
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 ¼ 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 (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. NR511: Differential Diagnosis and Primary Care
· 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. IF you ordered a test or performed a procedure, identify the corresponding Current Procedural Terminology (CPT) code(s). If not applicable, list n/a. 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. NR511: Differential Diagnosis and Primary Care

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