For this Discussion, you will take on the role of a clinician who is building a health history for one of the following cases.
A 11-year-old female patient complains of red left eye and edematous eyelids. Her mother states the child complains of “sand in my left eye.”
Patient noticed redness three days ago. Denies having any allergies. Symptoms have gotten worse since she noticed having the problem.
Objective Data
VS: (T) 98.2°F; (RR) 18; (HR) 78; BP 128/82; SpO2 96% room air; weight 110 lb.
General: well-developed, healthy, 11 years old
HEENT: EYES: very red sclera with dried, crusty exudates; unable to open eyes in the morning with the left being worse than the right
SKIN: CTA AP&L
Once you received your case number, answer the following questions:
1. What other subjective data would you obtain?
2. What other objective findings would you look for?
3. What diagnostic exams do you want to order?
4. Name 3 differential diagnoses based on this patient presenting symptoms?
5. Give rationales for your each differential diagnosis.
Submission Instructions:
• Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 3 academic sources.
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Case Number: 0045
As a clinician, it is essential to obtain a comprehensive health history of the patient to understand the problem better and plan the appropriate care. The patient is an 11-year-old female presenting with a red left eye and edematous eyelids. The patient’s mother reports that the child complains of “sand in my left eye,” and the symptoms have worsened since she noticed the problem. The following are the answers to the questions asked to create a comprehensive health history of the patient.
What other subjective data would you obtain?
In addition to the information given, I would obtain additional subjective data about the patient’s medical history, family history, and social history. The patient’s medical history would include past illnesses, allergies, surgeries, medications, and immunizations. I would also inquire about the family’s medical history, specifically if anyone in the family has a history of eye problems or any genetic disorders. The social history would include questions about the patient’s environment, living conditions, and habits such as smoking, alcohol intake, and drug use. It would also be essential to know if the patient has been exposed to any irritants or allergens lately.
What other objective findings would you look for?
Apart from the objective data provided, I would examine the patient’s eye to check for any inflammation, discharge, or changes in the shape or size of the eye. I would also assess the patient’s visual acuity and look for any signs of vision impairment. Additionally, I would check for the presence of lymph nodes around the patient’s neck, head, and face to rule out any other underlyinginfections or systemic diseases.
What diagnostic exams do you want to order?
To diagnose the patient’s condition accurately, I would order several diagnostic exams, including a comprehensive eye exam to assess the patient’s visual acuity, eye pressure, and visual field. I would also perform a slit-lamp examination to check for any signs of inflammation, infections, or other abnormalities. Additionally, I would order a complete blood count (CBC) and a urinalysis to rule out any systemic infections or underlying medical conditions.
Name 3 differential diagnoses based on this patient’s presenting symptoms?
Based on the patient’s presenting symptoms, the three differential diagnoses are:
Conjunctivitis
Corneal abrasion
Uveitis
Give rationales for your each differential diagnosis.
Conjunctivitis: Also known as pink eye, conjunctivitis is an inflammation of the conjunctiva, the thin layer that covers the white part of the eye. The patient’s symptoms, such as redness, edema, and discharge, are consistent with conjunctivitis. Conjunctivitis can be caused by viruses, bacteria, or allergens.
Corneal abrasion: A corneal abrasion is a scratch or injury to the cornea, the clear front part of the eye. The patient’s complaint of sand in her left eye could indicate a foreign body lodged in the eye, leading to a corneal abrasion. Other symptoms of corneal abrasion include pain, tearing, and sensitivity to light.
Uveitis: Uveitis is an inflammation of the uvea, the middle layer of the eye. The patient’s symptoms, such as redness, pain, and photophobia, are consistent with uveitis. Uveitis can be caused by autoimmune disorders, infections, or injuries.
In conclusion, the patient’s health history, along with a comprehensive physical examination and diagnostic tests, will help diagnose the patient’s condition accurately. It is essential to rule out any underlying systemic diseases and prescribe the appropriate treatment for the patient’s presenting symptoms.
