Nursing Career Review Sample Essay.
Category: Nursing
REQUIREMENTS:
- 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.
- 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.
- 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.
Case Study
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 | |
| Medications | Loratadine 10mg daily and fluticasone nasal spray daily (only takes during the spring months when nasal allergies flare) |
| 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.
| 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. Slight light sensitivity noted bilaterally. 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. |
| 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. |
| 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. |
**To see view the grading criteria/rubric, please click on the 3 dots in the box at the end of the solid gray bar above the discussion board title and then Show Rubric.
| DISCUSSION CONTENT Category Points % Description Application of Course Knowledge 15 30% A brief AND concise summary of the history and physical (H&P) findings is presented without redundancy or irrelevant information; AND Three (3) appropriate diagnoses in the differential are presented which can explain the patient’s chief complaint; AND A brief statement of pathophysiology is included for each diagnosis; AND Each diagnosis in the differential is analyzed using pertinent positive and negative subjective and objective findings as support; AND The differential is ranked in order from most likely to least likely; AND Clinical reasoning skills are demonstrated by linking testing to diagnoses as applicable; AND Testing decisions are well supported with EBM arguments that are in-line with the clinical scenario and appropriate for the primary care setting (7 critical elements) Support from Evidence-Based Practice (EBP) 15 30% Discussion post is supported with appropriate, scholarly sources; AND Sources are published within the last 5 years (unless it is the most current CPG); AND Reference list is provided and in-text citations match; AND All testing decisions are fully supported with an appropriate EBM argument (4 critical elements) Interactive Dialogue 10 20% Student provides a substantive* response to at least one topic-related post of a peer; AND Evidence from appropriate scholarly sources are included; AND Reference list is provided and in-text citations match; AND Student responds to all direct faculty questions (*) A substantive post adds new content or insights to the discussion thread and information from student’s original post is not reused in peer or faculty response (4 critical elements) Total CONTENT Points= 40 pts DISCUSSION FORMAT Category Points % Description Organization 5 10% Case study response is presented in a logical format, AND Responses are in sequence with the numbered questions AND The case study response is understandable and easy to follow AND All responses are relevant to the case topic (4 critical elements) Grammar, Syntax, Spelling & Punctuation 5 10% Discussion post has minimal grammar, syntax, spelling, punctuation, or APA format errors* Total FORMAT Points= 10 pts DISCUSSION TOTAL= 50 pts |
Student’s Name
Institutional Affiliation
NR511 Week 3
- 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.
A college student in their freshman year, aged 19, presented today in the school’s health clinic with a CC of persistent severe bilateral eye irritations that started ST x 2-3 days ago. He has redness, an itch, tearing, and a foreign body feeling. His right and left eyes experience what he describes to be gritty pain ranging from mild to moderate. The abrasive sensation was likened to sand stuck in the eyes. He responded negatively to ever wearing spectacles or contact lenses and has also never experienced similar symptoms. When asked when the last eye check-up was, the answer was somewhat vague as he answered that it was a few years ago. He has not been a victim of eye trauma or any surgery that may have triggered these symptoms. Collectively, there is no history of wearing contact lenses, lid crusting, mucoid discharge, or any recent illnesses of the heart, CNS, lung, skin, or joints.
- Provide a differential diagnosis (minimum of 3) which might explain the patient’s chief complaint, along with a brief statement of pathophysiology for each.
Differential diagnoses that may account for the chief complaint and their resultant pathophysiology are:
- Allergic conjunctivitis.
The symptoms are similar to what the patient describes: itching the eyes, watering and tearing, redness, and discomfort. Simultaneously, allergic conjunctivitis does not obscure visual perception. They may be caused by dust, mold, animal fur, and even seasonal factors such as pollen and grass. The symptoms are also experienced bilaterally in the eyes and are not contagious.
- Bacterial Conjunctivitis
Bacterial conjunctivitis is characterized by a purulent discharge and also causes reddening of the eyes (Watson, Cabrera-Aguas & Khoo, 2018). It is the result of an infection of the mucous membrane of the eye. It is caused by staphylococcus and streptococcus bacteria.
- Viral conjunctivitis
It is centered on inflammation or infection to the transparent membrane laminating the globe and the inner side of the eyelids. The symptoms related to this condition include an itchy feeling, a burning sensation, a tendency of the eyelids to remain stuck together after one has woken up, and having a foreign body sensation that is quite irritating (Watson, Cabrera-Aguas & Khoo, 2018). Like allergic conjunctivitis, it does not affect vision. Also, the reaction to light is normal, and the size of the pupil does not vary outside the norm.
- Analyze the differential by using the pertinent findings from the history and physical to argue for or against a diagnosis.
- Allergic conjunctivitis
The symptoms align with all the characteristics exhibited by the 19-year old, with the main ones being irritation of the eyes and tearing. These two have been mentioned in the history and physic examinations. Simultaneously, the patient has a runny nose and experiences nasal cavity congestion, making it somewhat difficult to breathe freely. When the eye assessment got conducted, there was no mass observed on either eyelid. Also, there was no evident crusting or any lesions forming. Bilateral conjunctiva coupled with redness and tearing were noted, but there was the absence of a mucoid or purulent discharge. With the above symptoms, one can satisfactorily eliminate viral and bacterial conjunctivitis and get inclined to diagnose the patient with allergies instead. The first two tend to affect one eye at first, gradually spreading to infect the other (Yeu & Hauswirth, 2020). The process takes a few days, yet allergic conjunctivitis affects both eyes simultaneously, as seen in the patient.
ii) Bacterial conjunctivitis
Bacterial conjunctivitis is characterized by reddening of the eyes and a purulent or mucoid discharge (Watson, Cabrera-Aguas & Khoo, 2018). The symptoms are first noticed on one eye, and when not treated immediately, the infection gradually spreads to the other. The patient, however, did not mention such progression in the disease. There are also other strong positive predictors of bacterial conjunctivitis. They include the tendency of the eyelid to remain glued together when one wakes up, mattering of eyelids in both the left and right eye, no itching or irritation, and no history of conjunctivitis. These have not been observed in the patient, making it solid to dismiss and argue against the diagnosis.
iii) Viral conjunctivitis
Viral conjunctivitis is a condition that is linked to infections in the upper respiratory tract of a patient (Yeu & Hauswirth, 2020). In this case, the lymph nodes get infected and become more tender and bigger. During the patient’s assessment, there was WNL. It may also be caused by exposure to an individual who may have had reddened eyes. The infections of the eye may be bilateral or unilateral. Also, patients tend to experience ocular itching, tearing of the eyes, reddening, and a foreign body sensation. The patient denied having any form of illness or infection in the upper respiratory tract, which may indicate viral conjunctivitis.
- Rank the differential in order of most likely to least likely.
The order of differential diagnosis in the rank of most likely to least likely is:
- Allergic conjunctivitis
- Viral conjunctivitis
- Bacterial conjunctivitis
- Identify any additional tests and/or procedures that you feel are necessary or needed to help you narrow your differential. All testing decisions must be supported with 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.
No tests are needed since this is a case of allergic conjunctivitis. Allergic conjunctivitis is the number one cause of red eyes globally. It affects about one billion people, though the causative agents may vary. Some are allergic to seasonal causatives such as grass and pollen, while others are sensitive to dust, animal fur, and particular flowers. The typical symptoms are itchiness, redness, and epiphora. Though more mildly, photophobia is also a classic symptom. The most recommended treatment procedure to allergic conjunctivitis is avoidance. It is not only the safest in terms of zero side effects, but it is the most effective and relatively cheap (Sowka, Gurwood & Kabat, 2016). It has proven to be significantly effective for allergy asthmatics and patients having occupational allergies (Sowka, Gurwood & Kabat, 2016). Practicing avoidance may include covering blankets, mattresses, and pillows to prevent collecting dust and other causative agents. One may also lower the humidity levels and replace carpets with solid surfaces and flooring such as tiles or hardwood planks. Adopting several adjustments at home and workplace environments can effectively minimize exposure to triggers and can be very beneficial. When avoidance is not fully effective or when it is not possible, one can opt for non-pharmaceutical and pharmaceutical measures. The former includes artificial tears and cold compresses. The latter include prescriptions of oral allergy or ophthalmic medications. When symptoms persist or when it becomes severe, one should set an appointment with an allergist.
References
Sowka, J., Gurwood, A., & Kabat, A. (2016). The Handbook of OCULAR DISEASE MANAGEMENT [Ebook] (18th ed.). Review of Optometry. Retrieved from https://www.reviewofoptometry.com/CMSDocuments/2016/6/hod0616i.pdf
Watson, S., Cabrera-Aguas, M., & Khoo, P. (2018). Common eye infections. Australian Prescriber, 41(3), 67. doi: 10.18773/austprescr.2018.016
Yeu, E., & Hauswirth, S. (2020). <p>A Review of the Differential Diagnosis of Acute Infectious Conjunctivitis: Implications for Treatment and Management</p>. Clinical Ophthalmology, Volume 14, 805-813. doi: 10.2147/opth.s236571