Case Study Part 1
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 disco
...
Case Study Part 1
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
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