Differentials Diagnosis and Primary Care Practicum Paper

Differentials Diagnosis and Primary Care Practicum Paper

The rest of the information from this case study will be attached as a PDFs file. 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.Differentials Diagnosis and Primary Care Practicum Paper
Provide a differential diagnosis (minimum of 3) which might explain the patient\'s chief complaint along with a brief statement of pathophysiology for each.

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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.Differentials Diagnosis and Primary Care Practicum Paper
Identify any additional tests and/or procedures that you feel is necessary or needed to help you narrow your differential. 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. Differentials Diagnosis and Primary Care Practicum Paper

DISCUSSIONS
WEEK 3: DISCUSSION PART ONE
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.Differentials Diagnosis and Primary Care Practicum Paper
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"Differentials Diagnosis and Primary Care Practicum Paper
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.Differentials Diagnosis and Primary Care Practicum Paper
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.Differentials Diagnosis and Primary Care Practicum Paper
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.Differentials Diagnosis and Primary Care Practicum Paper
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)Differentials Diagnosis and Primary Care Practicum Paper
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.Differentials Diagnosis and Primary Care Practicum Paper
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.
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.Differentials Diagnosis and Primary Care Practicum Paper
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.Differentials Diagnosis and Primary Care Practicum Paper
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.Differentials Diagnosis and Primary Care Practicum Paper
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.Differentials Diagnosis and Primary Care Practicum Paper
Identify any additional tests and/or procedures that you feel is necessary or needed to help you
narrow your differential. 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.Differentials Diagnosis and Primary Care Practicum Paper