Case Study The H&P Findings

Case Study The H&P Findings

• A 19-year old male patient came to the hospital complaining of bilateral eye discomfort. He claimed of itching, red and tearing eyes, which started 2 to 3 days before the present visit. On the pain scale, he rated the discomfort as 2/10. He described the pain as a constant ‘gritty’ or sand like feeling on the eye.
• He claims that he has been using OTC Visine drops, which improves the redness but does not relieve the irritations. Denies any recent eye trauma, dryness, visual changes, purulent drainage, glasses/contacts, or crusting.
• Complains of the occasional congested running nose, which is not accompanied by sneezing.
• Confirms having a seasonal allergy history, which comes up only in the springs, and manages it by Fluticasone Nasal spray and loratadine 10 mg daily PO.
• His eye was last examined approximately a year before the present visit, a

  

  nd it was discovered that he had a vision of 20/20 in both eyes, of which he does not wear corrective lenses or contacts.

• He denies any throat pain or redness, ear pain, chills, fever, SOB or wheezing, chest pain, or lymph node swelling/discomfort.
• Socially, he denies smoking marijuana. He admits taking 2 to 3 beers every weekend. He is a freshman college student at the University of Awesome in central Illinois and originates from AZ.
• He was adopted and not aware of his family history.
• Physical Findings:

Vital signs: T- 97.9; HR 68; BP 120/75; WT 195 lbs.; HT 6’0”

Physical findings essentially negative except for boggy and pale nasal turbinate in addition to clear nasal drainage and mild to moderate swelling. He has red conjunctiva tearing bilaterally. Visual acuity is still 20/20 (uncorrected) with no mass, foreign objects, crusting or lesions. Fundoscopic examination WNL.

Differential Diagnosis

Pathophysiology:

1. Allergic Conjunctivitis/Rhinitis: It is an eye infection caused by an inflammatory response induced by allergens, which interact with IgE antibodies of the mast cells leading to an ocular allergic response. It is a form of an IgE mediated hypersensitivity reaction. This condition presents in the form of redness, purpuritis, burning sensation, photophobia and tearing (Leonardi et al., 2017). Allergic rhinitis, on the other hand, occurs when one is exposed to allergens, and it presents with symptoms of nasal congestion, rhinorrhea, nasal itchiness, cough, and postnasal drip.
2. Bacterial conjunctivitis: It is an eye condition caused by bacterial pathogens. Bacteria such as, streptococcal pneumoniae, staphylococcal bacteria, and Hemophilus influenza invade the conjunctiva leading to an immune response, which causes inflammation. This condition presents with crust on the eyelids, purulent eye discharge, grittiness feeling and eye pain (Leung, Hon, Wong, & Wong, 2018).
3. Sinusitis: A comprehensive understanding of rhinosinusitis pathophysiology is still unclear. However, most scientists have tried to explain it using the identified numerous inflammatory pathways and infections. This eye condition can either be bacterial or viral in nature. Bacterial sinusitis is usually as result of Streptococcus pneumonia, Moraxella catarralls or Hemophilus pneumonia. Bacterial sinusitis is usually accompanied by a greenish or yellowish discharge and is controlled by antibiotics (Kim et al., 2019). Viral sinusitis, on the other hand, presents with symptoms of rhinorrhea, nasal congestion, sore throat, facial and dental pain, headache, and low-grade fever. Viral sinusitis can also progress from a common cold. Consequently, bacterial sinusitis can also develop as a result of bacterial sinusitis. Uncontrolled allergic rhinitis can also progress to early sinusitis.

Click here to ORDER an A++ paper from our MASTERS and DOCTORATE WRITERS: Case Study The H&P Findings

Analysis of the Differential Diagnosis by Use of the H&P Findings

1. Allergic Conjunctivitis/ Rhinitis:

Positive for itching and burning sensation of the eye, which is bilateral, tearing, and has rhinorrhea. The patient has

also been exposed to new allergens given the change in geographical location.

Negative for purulent discharge and photophobia.

2. Bacterial Conjunctivitis:

Positive for itching and burning eye sensation, tearing and redness of the eyes, with no visual interruption.

Negative for sore throat, no facial pain, no greenish or yellowish discharge from the eyes, no headache, no malaise or fever.

3. Sinusitis:

Positive for itching and burning eye sensation, rhinorrhea, and frequent allergic reactions in the past.

Negative for lack of crust on the eyelids, no subconjunctival hemorrhage, no crusted eyelids, no edema.

 

Differential Diagnosis Ranking

The 19-year-old’s patient presenting illness is mostly as a result of seasonal allergy exacerbation. In as much as the case study does not specifically mention the season in which the patient is currently in, the fact that he moved from his original to a new environment shows that he might have encountered more allergens in the new environment which are precipitating his presenting illness. However, when a bilateral eye examination was conducted, there were no signs of debris on his eye or the eyelid ruling out some of the possible infections that he might be suffering from. However, there is a possibility that other infectious pathogens might have been the reason behind his current health status. Considering the analysis discussed above, I would rank allergic conjunctivitis as my priority diagnosis followed by bacterial conjunctivitis and lastly sinusitis just as listed below.

1. Allergic Conjunctivitis/Rhinitis
2. Bacterial conjunctivitis
3. Sinusitis

 

Test and/or Procedures

1. Allergic Conjunctivitis/ Rhinitis: No specific diagnostic test is required for allergic conjunctivitis. However, the CDC recommends that the diagnosis of this eye complication should be based on the patient history taken, the symptoms displayed and physical examination findings, which had already been done. Inclusion criteria include symptoms such as redness of the eye, swelling, itching and burning sensation. The symptoms are also used as a tool for finding the causes of the infection. It is also important to note that all the symptoms of allergic conjunctivitis are bilateral. The infection is also accompanied by mucoid or watery discharge from the eye (Leonardi, Castegnaro, Valerio, & Lazzarini, 2015). The healthcare provider must also consider the fact that the infection is mostly seasonal and presents commonly in patients with a history of allergic reactions, atopic dermatitis, asthma, and hay fever. However, tests such as total serum IgE and total blood eosinophil count could be done to qualify the diagnosis.
2. Bacterial Conjunctivitis: Diagnosis of bacterial conjunctivitis majorly depends on the physical examination findings, symptoms and specific lab tests. The clinician can look for signs of redness of the eye, quality, and quantity of eye discharge, pain, photophobia, blurry vision, trauma, itching, foreign body sensation, and use of contact lenses. Slit lamp biomicroscope evaluation of the cornea is also necessary to rule out the cause by foreign bodies. Conjunctival scrapings and cultures are necessary for identification of the causative bacteria. Imaging studies are not necessary, in case of suspected cavernous sinus fistula, MRA, CT scan, and orbital color Doppler may be necessary (Wolffsohn et al., 2017).
3. Sinusitis: This condition is mostly clinically diagnosed based on the symptoms, patient’s history and findings from physical examinations. However, other lab tests such as nasal cytology, nasal sinus biopsy and tests for immunodeficiency, ciliary dysfunction or cystic fibrosis might also be necessary. Nasal cytology tests are relevant in elucidating eosinophilia, nasal polyposis, allergic rhinitis and aspirin sensitivity (Kim et al., 2019). Immunodeficiency tests are necessary when there is a history of recurrent infection, and they include immunoglobulin studies.

 

 

References

Kim, Y., Lee, K. J., Sunwoo, L., Cho, J., Bae, Y. J., Yoo, R.-E., Choi, B. S., … Yoo, R.-E. (January 01, 2019). Deep Learning in Diagnosis of Maxillary Sinusitis Using Conventional Radiography. Investigative Radiology, 54(1), 7-15.

Leonardi, A., Castegnaro, A., Valerio, A. L., & Lazzarini, D. (January 01, 2015). Epidemiology of allergic conjunctivitis: clinical appearance and treatment patterns in a population-based study. Current Opinion in Allergy and Clinical Immunology, 15(5), 482-8.

Leonardi, A., Doan, S., Fauquert, J. L., Bozkurt, B., Allegri, P., Marmouz, F., Rondon, C., … Calder, V. (October 01, 2017). Diagnostic tools in ocular allergy. Allergy, 72(10), 1485-1498.

Leung, A. K. C., Hon, K. L., Wong, A. H. C., & Wong, A. S. (January 01, 2018). Bacterial Conjunctivitis in Childhood: Etiology, Clinical Manifestations, Diagnosis, and Management. Recent Patents on Inflammation & Allergy Drug Discovery, 12(2), 120-127.

Wolffsohn, J. S., Arita, R., Chalmers, R., Djalilian, A., Dogru, M., Dumbleton, K., Gupta, P. K., … Craig, J. P. (July 01, 2017). TFOS DEWS II Diagnostic Methodology report. The Ocular Surface, 15(3), 539-574.