Requirements: Briefly and concisely summarize the history and physical (H&P) fin

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 StudyDate of visit: October 20, 2017A 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 IllnessOnset2-3 days agoLocationBoth eyesDurationConstantCharacteristicsBoth eyes feel “gritty” with mild to moderate amount of discomfort. Further describes the gritty sensation “like sand caught in your eye”Aggravating factorsNone identifiedRelieving factorsNone identifiedTreatmentsTried OTC visine drops once yesterday which temporarily improved the redness but the gritty sensation, tearing and itching remained.SeverityLevel of discomfort is 2/10 on pain scaleReview of Systems (ROS)ConstitutionalDenies fever, chills, or recent illnessesEyesDenies 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, -otorrheaNose+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).ThroatDenies ST and rednessNeckDenies lymph node tenderness or swellingChestDenies cough, SOB and wheezingHeartDenies chest painHistoryMedicationsLoratadine 10mg daily and fluticasone nasal spray daily (only takes during the spring months when nasal allergies flare)PMHSeasonal allergic rhinitis with springtime triggersPSHNoneAllergiesNoneSocialFreshman student at the University of Awesome located in central Illinois. Home is in Phoenix.HabitsDenies cigarettes +recreational marijuana use +drinks 3-6 beers per weekendFHAdopted, does not know biological parents historyPhysical exam reveals the following.Physical ExamConstitutionalYoung adult male in NAD, alert and oriented, cooperativeVSTemp-97.9, P-68, R-16, BP 120/75, Height 6’0, Weight 195 poundsHeadNormocephalicEyesVisual 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.EarsTympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender.NoseNares patent. Nasal turbinates are pale and boggy with mild to moderate swelling. Nasal drainage is clear.ThroatOropharynx moist, no lesions or exudate. Tonsils ¼ bilaterally. Teeth in good repair, no cavities noted.NeckNeck supple. No lymphadenopathy. Thyroid midline, small and firm without palpable masses.CardiopulmonaryHeart 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
Requirements: 1 page

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