NR 511 Case Study Week 3 Part 1 Gail-Marie Stewart NR 511
Week 3 – Case Study Part 1
1. Case Summary
• 19 yo male presents with a CC of bilateral
... [Show More] mild to moderate eye discomfort onset 2-3 days. Reports discomfort is constant and feels “gritty” “like sand” in his eyes and rates it 2/10. Patient does not report any aggravating or relieving factors, however, has tried
OTC visine gtts 1x yesterday. Gtts reduced redness in eyes but did not reduce gritty sensation, tearing or itching.
• Patient does not wear glasses or contact lenses, denies eye injury, trauma, or dryness. Denies any mucoid or purulent drainage from eyes or crusting of lids
• Upon physical exam visual acuity is 20/20 (uncorrected) OU, PERRLA, slight light sensitivity bilaterally. Diffuse redness to conjunctiva present but no FB present bilaterally. Fundoscopic exam unremarkable with flat retinal discs and sharp margins.
Retinal background WNL w/o presence of hemorrhages. Nasal turbinate’s mild and boggy bilaterally with mild to mod. swelling and clear drainage. ENT negative for soreness or enlarged tonsils or exudate.
• Currently prescribed Loratidine 10mg daily for seasonal allergies; fluticasone nasal spray daily (only during Spring when allergies flare up) – Patient is not taking either
medication at the moment.
2. Differential Diagnoses
• Allergic Conjunctivitis
o Caused by the body’s response to an allergic stimulus that is most often
environmental which cause a “systemic humoral or local histaminic response” (Dunphy, 2019, p. 273). There are three main types of non-severe allergic conjunctivitis; seasonal (typically spring), perennial (year-round caused by dust and other environmental factors), and acute allergic conjunctivitis (Marais 2017)
• Corneal Abrasion
o Caused by trauma (physical or chemical) to the cornea. When the epithelial layer
of the cornea is damaged, the healing process in response to the limbal epithelium can cause mild to moderate discomfort. The epithelium conjunctiva can also cause signs and symptoms consistent with excessive tearing, itching and burning (Verum, 2019).
• Dry Eye (kerato-conjunctivitis sicca)
o Caused by decreased tear production or inadequate tear quality. Dunphy (2019)
indicates that dry eye disease is also caused by release of cytokines which initiate an inflammatory response along with “lymphocytic infiltration (CD4 T cells and B cells) of [both the] lacrimal and salivary glands” (p. 267). Androgen and estrogen receptors are also located in the lacrimal and Meibomian glands which when decreased can cause decrease lacrimal duct function and decreased tear production. Autoimmune diseases such as Sjögren is also possible but is most prevalent in females (Dunphy, 2019).
3. Analyze the Differential [Show Less]