NURS6541C iHuman Ramona Frankel Caucasian Female wk 4 Red
Eye Case Study
Patient Information: RF, 6-year-old, Caucasian, Female
Subjective:
CC (chief
... [Show More] complaint): Red eye
HPI: Ramona is a 6-year-old female who presents today with her mother with complaints of
redness to her right eye. The redness began 3 days ago and is associated with purulent discharge
that becomes worse overnight. She has red conjunctiva with purulent exudate of the right eye
without pain, tenderness, or swelling. Left eye normal appearing. She has had nasal congestion
for 3 days. The mother reports that 2 other children from school have similar symptoms.
Ramona was sent home from school today with instructions that she was to be evaluated before
returning to school. Physical exam with findings of right eye conjunctival injection and purulent
discharge. There is no decreased vision or ulcerations. Nasal passages normal appearing. No
significant past medical history.
Current meds: None
Allergies: NKDA
Pertinent PMHx: Ramona is in general good health. No pertinent past medical history noted.
She is up to date on immunizations and has regular check-ups.
Immunizations:
Hep B - series completed at 18 months
RV1 - series completed at 4 months
DTaP - series completed at 5 years
Hib - series completed at 15 months
PCV13 - series completed at 15 months
IPV - series completed at 5 years
IIV – Annual vaccination completed at 5 years
MMR - series completed at 5 years
VAR - series completed at 5 years
Hep A - series completed at 18 months
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https://www.coursehero.com/file/115320093/MillerC-wk4-ihumanRamonaFrankel6541Cdocx/
NURS6541C iHuman Ramona Frankel Caucasian Female wk 4 Red
Eye Case Study
Social hx: Lives at home with mother and father in an apartment. No siblings. Mother is an
engineer. Father works in finance.
Fam Hx:
1. Mother, 38-years-old, healthy
2. Father, 40-years-old, healthy
History Questions Asked:
1. How can I help you today?
2. What symptom is most distressing for you?
3. What happened?
4. How can I help her today?
5. Does she have any other symptoms or concerns we should discuss?
6. Does she have pain anywhere? If so, where?
7. Do you have pain anywhere? If so, where?
8. Has anyone else she knows developed these symptoms?
9. When did her eye problems start?
10. How quickly did her eye problem come on?
11. Does anything make her eye problem better or worse?
12. Has she noticed any discharge from her eye, especially when she wakes up from
sleeping?
13. Does she have any other symptoms associated with her eye problem?
14. Has she had this eye problem before?
15. What treatments has she had for her eye problem?
16. Are there any other people she has had contact with who have a similar eye problem?
This study source was downloaded by 100000859807096 from CourseHero.com on 02-13-2023 06:32:41 GMT -06:00
https://www.coursehero.com/file/115320093/MillerC-wk4-ihumanRamonaFrankel6541Cdocx/
NURS6541C iHuman Ramona Frankel Caucasian Female wk 4 Red
Eye Case Study
17. Are her eyes tearing and/or itching?
18. Does she see any flashing lights?
19. Does she have any sensitivity to light?
20. Is she having trouble with her vision?
21. Does she have a runny nose/nasal congestion?
22. Does she have a sore throat?
23. Has she ever been hospitalized?
24. What childhood illnesses has she had?
25. Does she have any allergies?
26. Is she taking any prescription medications?
27. Is she taking any over-the-counter medications?
28. Can she swallow pills?
29. Has she been having fevers?
30. How is her overall health?
31. Doses she have a cough?
32. Does she have sinus pain?
33. Does she have nose bleeds?
34. Does she have double vision?
35. Does she have any dimming in her vision?
36. Has she noticed any distortions or loss of her central vision?
37. Are her eyes red/and or irritated?
38. Are her swollen glands painful, tender, hard or draining?
39. Does she have any swollen lymph nodes? [Show Less]