Skin, Eye and Ear Disorders Essay

Skin, Eye and Ear Disorders Essay

Subjective Data

Subjective data is information obtained from a patient. It includes patient particulars, the chief complaint, history of the presenting complaint, the past medical and surgical history, family history, personal social-economic history, review of systems, and gynecology history. This patient’s particulars are, T.T an 11-year-old female who has been accompanied by the mother. The chief complaint is redness and edema of the left eye for three days. The history of presenting complaints is redness and edema of the left eye associated with foreign body sensation for three days. The patient reports that it has been progressing since the onset. It has a dry sclera with crusty exudates and an inability to open the eye in the morning. I would ask if the patient has had eye trauma previously, skin allergies, visual disturbance, migraine, lacrimation, nasal congestion, sneezing, rhinorrhea, sore throat, and general malaise. Skin, Eye and Ear Disorders Essay

In the past medical history, the patient denies having allergies. I would also ask about previous admissions, surgical procedures, blood transfusion, current medication, known food and drug allergies, and chronic illnesses. In the review of systems I would ask her if she has symptoms related to the cardiovascular, respiratory, genitourinary, gastrointestinal, and musculoskeletal systems. In her personal history, I would ask her about her hobbies, social history I will ask about her school performance and relationship with friends and parents, and family history, I would ask about her family members and chronic illnesses that are in the family. Skin, Eye and Ear Disorders Essay

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Objective Data

Objective data is the information the clinician acquires through physical and systemic examination. It involves the vitals, general examination, and systemic examination. The patient’s vitals are the temperature at 98.2F, respiratory rate at 18 cycles per minute, heart rate at 78beats per minute, blood pressure at 128/83, sp02 at 96% room air, and weight 110 Ib. On general examination, the child is well developed and healthy. The eyes have a very red sclera with dried cluster exudate and edematous. I would examine the retina, color vision testing, refraction, and glaucoma test. In the general examination, I would look for pallor, jaundice, lymphadenopathy, and dehydration. I would also examine the ear, nose, and throat for masses, secretions, or foreign bodies. In the skin, I would look for skin rashes and skin diseases.

Diagnostic Examination I Would Offer

For this patient, I would request for a white blood cell count to rule out bacterial or viral conjunctivitis. I would do a scleral swab for culture and sensitivity to grow the organism causing eye illness (Leung, et al, 2018). I would also do a fundoscopy to visualize the internal structure of the eye and RPS Adeno detector to help rule out viral conjunctivitis.

Differential Diagnosis

Acute viral conjunctivitis, blepharitis, and allergic conjunctivitis are the differential diagnoses for this patient. Skin, Eye and Ear Disorders Essay

Rationale For Each Differential

Acute viral conjunctivitis presents with redness of the eye, itchiness, gritty feeling, and lacrimation.  It is associated with general malaise and sore throat. Blepharitis presents with eye swelling, redness, irritation, itchiness, and dry sclera with crusty discharge (Amescua, et al, 2019). Allergic conjunctivitis is the inflammation of the eye caused by spores or pollen that leads to redness of the eyes, itchiness, and lacrimation.

Conclusion

The actual diagnosis for the patient is blepharitis because the patient has the presenting signs and symptoms. They are eye redness, swelling, dry sclera with crusty exudates, and difficulties in opening the eyes in the morning. Blepharitis may or may not be associated with itchiness and other allergy symptoms. Skin, Eye and Ear Disorders Essay

For this Discussion, you will take on the role of a clinician who is building a health history for one of the following cases. Your instructor will assign you your case number. 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. 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 Neck/Throat-> No information provided 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 2 academic sources current (published within the last five years) scholarly journal articles).

References

Amescua, G., Akpek, E. K., Farid, M., Garcia-Ferrer, F. J., Lin, A., Rhee, M. K., … & Mah, F. S. (2019). Blepharitis preferred practice pattern®. Ophthalmology, 126(1), P56-P93.

Leung, A. K., Hon, K. L., Wong, A. H., & Wong, A. S. (2018). Bacterial conjunctivitis in childhood: etiology, clinical manifestations, diagnosis, and management. Recent patents on inflammation & allergy drug discovery, 12(2), 120-127. Skin, Eye and Ear Disorders Essay