NR 511 Wk1 P1 Assignment

NR 511 Wk1 P1 Assignment

NR 511 Wk1 P1 Assignment : M.S., 44yr, F, Caucasian,

 

CC: “eye looks red” and “goop in my eye”

 

HPI:

O: This morning

L: Which eye is red?

D: Is the redness constant or intermittent?

C: Are there any other associated symptoms with your red eye?

A: Does anything make the redness worse?

R: Does anything make the redness better?

T: Have you treated the red eye in any way? Cold compress, medications, drops?

S: How severe or red is it comparatively to normal?

 

Do you wear eyeglasses or contact lenses (for the exams)?

Do you have any vision deficits?

 

 

Differential Diagnosis:

1. Acute bacterial conjunctivitis (ICD-10 H10.30) – A contagious infection and inflammation often caused by gram-positive organisms (McCance & Huether, 2014).

Positives: May involve one or both eyes, inflammation of the eye, absence of fever, absence of itchiness and watery eyes

Negatives: Discharge

2. Viral Conjunctiva (ICD-10.CM B30.9) – A contagious acute infection and inflammation of the conjunctiva, often caused by an adenovirus (McCance et al., 2014).

Positives: May involve one or both eyes, Inflammation of the eye, in close proximity with another person that may also have the same symptoms

Negatives: Discharge, absence of fever, absence of itchy eyes, absence of burning eyes

3. Allergic Conjunctivitis (ICD.10 H10.11) – An acute inflammation of the eye related to a variety of antigens (McCance et al., 2014).

Positives: Inflammation of the eye, absence of discharge, co-habitat with 2 dogs and a cat, family members that smoke.

Negatives: absence of Bilateral eyes, absence of itchy and watery eyes

 

PE:

HEENT: Inspect face, throat, oral cavity, ears and eyes.  Note the pharynx and tonsils.  Inspect ears and eyes with otoscope and ophthalmoscope.  Perform a  visual field test.  Palpate sinuses, lymph nodes, and neck.

Heart/Lungs: Auscultate heart and lungs

NR 511 Wk1 P1 Assignment

Dx Tests and Labs:

Conjunctival Smear – The initial smear examination of the sample can provide a rapid diagnosis.  Smears may provide etiological diagnosis that may not require further diagnostic tests such as cultures (Sharma, 2012).  The most commonly used stain that demonstrates and distinguish the presence of bacteria, fungi and parasites is the gram stain (Sharma, 2012).  The quick results of the smear would provide quick diagnosis for the patient with minimal effort.

 

 

 

1. S., 7yr, F, Caucasian

 

CC: “Red eye”

 

HPI:

O: 2 days ago

L: Bilateral eyes

D: Are the symptoms (itchy, burning, drainage, and redness) constant or intermittent?

C: Burning and Itching

A: Does anything make the symptoms worse?

R: Does anything help make the symptoms better?

T: Have you treated the red eyes, drainage itchiness in any way? Or taken any medications or drops?

S: How severe or bad are the symptoms?

 

Do you wear eyeglasses or contact lenses (for the exams)?

Do you have any vision deficits?

Differential Diagnosis:

1. Viral Conjunctivitis (ICD-10.CM B30.9) – A contagious acute infection and inflammation of the conjunctiva, often caused by an adenovirus (McCance et al., 2014).

Positives: Discharge, may involve one or both eyes, inflammation of the eye, started with left eye and spread to right eye, co-habitat with smokers, itchy eyes

Negatives: burning eyes

2. Acute bilateral eyes bacterial Conjunctivitis (ICD-10. H10.233) – A highly contagious infection and inflammation often caused by gram-positive organisms (McCance & Huether, 2014).

Positives: Discharge, may involve one or both eyes, inflammation of the eye

Negatives: burning eyes

3. Allergic Conjunctivitis (ICD.10 H10.11) – An acute inflammation of the eye related to a variety of antigens (McCance et al., 2014).

Positives: Inflammation of the eye, itching, burning sensation, bilateral eyes, co-habitat with 2 dogs and a cat, family members that smoke.

Negatives: Discharge

 

PE:

HEENT: Inspect face, throat, oral cavity, ears and eyes.  Note the pharynx and tonsils.  Inspect ears and eyes with otoscope and ophthalmoscope.  Perform a visual acuity eye exam with a Snellen chart.  Perform a visual field test.  Palpate sinuses, lymph nodes, and neck.

Heart/Lungs: Auscultate heart and lungs

 

Dx tests and Labs:

Conjunctival Smear – The initial smear examination of the sample can provide a rapid diagnosis.  Smears may provide etiological diagnosis that may not require further diagnostic tests such as cultures (Sharma, 2012).  The most commonly used stain that demonstrates and distinguish the presence of bacteria, fungi and parasites is the gram stain (Sharma, 2012).  The quick results of the smear would provide quick diagnosis for the patient with minimal effort.

 

NR 511 Wk1 P1 Assignment

Reference

 

McCance, K., Huether, S. (2014). Pathophysiology: The Biologic Basis for Disease in Adults and Children, 7th Edition. [Bookshelf Online]. Retrieved from https://online.vitalsource.com/#/books/9780323088541/

 

Sharma, S. (2012). Diagnosis of infectious diseases of the eye. Eye, 26(2), 177-84. doi:http://dx.doi.org.proxy.chamberlain.edu:8080/10.1038/eye.2011.275