*NURSING > CASE STUDY > NR 511 Case Study Week 3 Part 1 091420.docxNR 511 Case Study Week 3 Part 1 19 yo male presents with (All)

NR 511 Case Study Week 3 Part 1 091420.docxNR 511 Case Study Week 3 Part 1 19 yo male presents with a CC of bilateral mild to moderate eye discomfort onset 2-3 days. Reports discomfort is constant and feels “gritty” “like sand” in his eyes and rates it 2/10. Patient does not report any aggravating or relieving factors, however, has tried OTC visine gtts 1x yesterday. Gtts reduced redness in eyes but did not reduce gritty sensation, tearing or itching. Patient does not wear glasses or contact lenses, denies eye injury, trauma, or dryness. Denies any mucoid or purulent drainage from eyes or crusting of lids Upon physical exam visual acuity is 20/20 (uncorrected) OU, PERRLA, slight light sensitivity bilaterally. Diffuse redness to conjunctiva present but no FB present bilaterally. Fundoscopic exam unremarkable with flat retinal discs and sharp margins. Retinal background WNL w/o presence of hemorrhages. Nasal turbinate’s mild and boggy bilaterally with mild to mod. swelling and clear drainage. ENT negative for soreness or enlarged tonsils or exudate. Currently prescribed Loratidine 10mg daily for seasonal allergies; fluticasone nasal spray daily (only during Spring when allergies flare up) – Patient is not taking either medication at the moment.

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NR 511 Case Study Week 3 Part 1 091420.docx NR 511 Case Study Week 3 Part 1 19 yo male presents with a CC of bilateral mild to moderate eye discomfort onset 2-3 days. Reports discomfort is consta... nt and feels “gritty” “like sand” in his eyes and rates it 2/10. Patient does not report any aggravating or relieving factors, however, has tried OTC visine gtts 1x yesterday. Gtts reduced redness in eyes but did not reduce gritty sensation, tearing or itching.  Patient does not wear glasses or contact lenses, denies eye injury, trauma, or dryness. Denies any mucoid or purulent drainage from eyes or crusting of lids  Upon physical exam visual acuity is 20/20 (uncorrected) OU, PERRLA, slight light sensitivity bilaterally. Diffuse redness to conjunctiva present but no FB present bilaterally. Fundoscopic exam unremarkable with flat retinal discs and sharp margins. Retinal background WNL w/o presence of hemorrhages. Nasal turbinate’s mild and boggy bilaterally with mild to mod. swelling and clear drainage. ENT negative for soreness or enlarged tonsils or exudate.  Currently prescribed Loratidine 10mg daily for seasonal allergies; fluticasone nasal spray daily (only during Spring when allergies flare up) – Patient is not taking either medication at the moment. [Show More]

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