NR 511 Case Study PT 1 Week 3 PDF

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Patient A.A, is a 19 yo female with a CC of bilateral eye discomfort that started 2-3 days ago. Patient states eyes feels gritty, sand-like feeling with mild to moderate amounts of discomfort; additionally, pain isn’t relieved with any form of treatment. Eye gtts administered x1 dose with temporary relief. No change in redness, gritty sensation, tearing, or itching. 3 Differential Diagnosis 1. Allergic conjunctivitis 2. Dry eye 3. Viral conjunctivitis The pathophysiology of allergic conjunctivitis is a benign disease which produces conjunctival edema, itching, tearing, redness, and possible stringy discharge; at times, the person may experience photophobia and visual loss. Allergic conjunctivitis may occur suddenly, or it can occur seasonally or perennially with the changing of the weather. The pathophysiology of dry eye can stem from a hereditary disorder, systemic disease, or systemic drug, furthermore, dry eye is more common in females and the chances of getting dry eye increases with age (Duncan, Parikh, Seitzman, & Riordan-Eva, chapter 7, 2020). Viral conjunctivitis, as Fromstein explains, (2018) stems from adenovirus which may produce signs such as lid edema lymphadenopathy, photosensitivity, fever, malaise, or eye redness (p.14). Diagnosis # 1: Allergic conjunctivitis is my #1 differential diagnosis and should be ruled out in a patient presenting with bilateral eye discomfort to prevent a reduction in activities of daily living or possibly vision loss if left untreated. Pertinent positive findings: Bilateral orbital itching. Mild to moderate discomfort, watery discharge, conjunctiva redness, light sensitivity, clear nasal drainage, with pale & boggy nasal turbinates. Nonpalpable preauricular lymph nodes. Pertinent negative findings: No cough or sneezy. Non-exposure to a person or item that is positive with a known active viral infection. Watery discharge usually doesn’t occur in allergic conjunctivitis.

Diagnosis #2: Dry eye syndrome (DES), is my 2nd preferable diagnosis because like many eye disorders, their common associated symptoms which can confuse the provider; however, DES is one of the many differential diagnosis which I discovered that produces that sandpaper gritty feeling that the patient presents with. Additionally, with DES, presenting symptoms may be eye discomfort, visual changes, or the failure of ocular tears to adequately lubricate the eye’s surface. Pertinent positives: Dry, gritty sandpaper feel to eye, conjunctiva redness, female gender, taking OTC antihistamines, +recreational marijuana use (smoking increases risk of dry eye), college student (viewing computer screen). Commonly affects both eyes. Pertinent negatives: No cough, visual changes or dryness. Non corrective lens wearer. No PMH of genetic disorder which produces dry eye. Diagnosis #3: Viral conjunctivitis: The reason I chose this as my 3rd differential diagnosis I is because this form of conjunctivitis is usually caused by a subtype of an adenovirus which can present in various ways. Pertinent positives: Experiencing light sensitivity and presently living in a college dorm environment. Conjunctivitis can occur in a single eye, however, when it occurs bilaterally, it more than likely stems from a viral or bacterial source. Erythematous conjunctiva, + tearing, itching and minimal pain. Signs of an upper respiratory infection such as clear nasal discharge and bilateral pale, boggy turbinates are presenting factors in VC. Pertinent negatives: No fever, malaise, photophobia, chills. People with this form of conjunctivitis may complain of burning as well as itching and watery discharge, in which she doesn’t complain of a burning sensation. Testing, Treatment, & Referral: I would perform an eye exam, testing simple procedures such testing of her visual acuity, in addition to the testing of her ocular nerves. I also would perform a Slit Lamp exam; this exam according to Yeu & Hauswirth (2020), will provide me with a more detailed appearance of the conjunctival epithelium, which may help diagnosis or differentiate between the various types of conjunctival inflammation (pp.805-813). Even though she isn’t experiencing discolored or purulent eye

discharge, current practice guidelines from the American Academy of Ophthalmology Cornea/External Disease Preferred Practice Pattern Panel (2018), clarified for providers that when a person presents with typical case of allergic conjunctivitis, the provider needs to educate the patient on comfort measures at home, however, in viral conjunctivitis, they state that VC usually starts with one eye, however, when VC presents bilaterally, this signifies a highly contagious adenovirus strain, which needs to be treated with topical antibiotics, even if the person does not have purulent discolored drainage (www.aao.org/preferredpractice-pattern/conjunctivitis-ppp). Artificial tears which can be purchased OTC can be given without causing any further irritation or damage. Furthermore, CPG’s from the American Academy of Ophthalmology (2017), recommends a topical antibiotic to treat the virus before it causes further damage. Additionally, I would recommend an OTC oral antihistamine such as Zyrtec, Claritin or Allegra for her ongoing allergic rhinitis. I, however, wouldn’t prescribe a topical antibiotic because I don’t have the proper equipment nor the expertise to safely and properly diagnose and treat her. I feel as though she needs an antibiotic, and although it seems miniscule not prescribe her one for something that’s occurs often in practice, I wouldn’t feel comfortable prescribing her because she has some of the symptoms for a prompt referral to an ophthalmologist per current AAO guidelines. The ongoing eye pain, excessive tearing, gritty sandpaper sensation, light sensitivity, and eye redness needs further investigation.

References: Duncan J.L., & Parikh N.B., & Seitzman G.D., & Riordan-Eva P (2020). Conjunctivitis. Papadakis M.A., & McPhee S.J., & Rabow M.W.(Eds.), Current Medical Diagnosis and Treatment 2020. McGrawHill. https://accessmedicine-mhmedical-com.chamberlainuniversity.idm.oclc.org/content.aspx? bookid=2683§ionid=225049136

Fromstein, S. (2018). Conjunctivitis: Making the call good judgment and a comprehensive look beyond signs and symptoms are integral to knowing whether it's allergic, bacterial or viral. Review of Cornea & Contact Lenses, (pp.14-17)

https://chamberlainuniversity.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx? direct=true&db=heh&AN=131800071&site=eds-live&scope=site Yeu E., & Hauswirth, S. (2020). A Review of the Differential Diagnosis of Acute Infectious Conjunctivitis: Implications for Treatment and Management. Clinical Ophthalmology, 14, (pp.805-813). American Academy of Ophthalmology Cornea/External Disease Preferred Practice Pattern Panel. Conjunctivitis Preferred Practice Pattern. San Francisco, CA: American Academy of Ophthalmology; 2018. https://www.aao.org/preferred-practice-pattern/conjunctivitis-ppp-2018.

Primary Diagnosis: Allergic Conjunctivitis ICD-10: H10.45 Pertinent positive findings: Bilateral orbital itching. Mild to moderate discomfort, watery discharge, conjunctiva redness, light sensitivity, clear nasal drainage, with pale & boggy nasal turbinates. Nonpalpable preauricular lymph nodes. Pertinent negative findings: No cough or sneezy. Non-exposure to a person or item that is positive with a known active viral infection. Watery discharge usually doesn’t occur in allergic conjunctivitis. Treatment Plan: Now that we know that all testing was normal, I would prescribe OTC/ prescription Pataday (Olopatadine Hydrochloride 0.2% solution), Disp 30-day supply or 2.5 ml bottle, Sig: Please instill 1 gtt twice daily as needed for dry, itchy eyes (allow 8 hours in between doses); 0 refills Singulair 10 mg tablet, Disp #30, Sig: 1 tab once daily for 30 days; 0 refills Rationale: According to Dunphy (2018), allergic conjunctivitis is treated with oral antihistamines and or ophthalmic gtts such as mast cell stabilizers, antihistamines, anti-inflammatories, or a combination of both. Walker & Adhikari (2020) explain that allergic conjunctivitis can be treated with just artificial tears alone, however, if the prescribed treatment doesn’t improve symptoms, I will refer patient to Ophthalmologist; so, no other treatment will be needed at this time (chapter 241). Active Problem List: Allergic rhinitis Dry Eye Light Sensitivity Excessive Orbital tearing Bilateral Ocular Pain Cannabis use, unspecified Alcohol use

Management: I would explain to the patient that there’s several OTC and at home treatment options for him depending on how he’s feeling in regard to his symptoms. Artificial tears can be used for excessive dry eye irritation, and if he does a lot of outside activities, I would recommend that he wear a form of wraparound sunglasses to keep wind/particles from getting into his eyes, drying them out even further. At home, a cool mist humidifier may help keep the eye’s moist and excessive dryness; additional treatment includes warm compresses for comfort and relief of itching. Follow-up with provider in 1 week if symptoms aren’t relived with recommended treatment regimen. Patient Education: Because allergic conjunctivitis can easily turn into a viral case, I would educate the patient on the proper use of hand & body hygiene in order to prevent infection. Again, educate on what to clean dormitory areas such as hard surfaces, where bacteria can proliferate, potentially infecting him and others within their residential setting.

Reference:

Walker, A. & Adhikari, S. (2020). Eye emergencies. Tintinalli J.E., & Ma O, & Yealy D.M., & Meckler G.D., & Stapczynski J, & Cline D.M., & Thomas S.H.(Eds.), Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill. https://accessmedicine-mhmedicalcom.chamberlainuniversity.idm.oclc.org/content.aspx?bookid=2353§ionid=222404436...