Mod.2 AdvH Discussion Reply

CASE STUDY 3----Additional Subjective Data

Additional subjective information related to a red sclera with dried, crusted exudates is necessary for an accurate diagnosis. When gathering this information, the practitioner should ask the patient direct questions because the patient is eleven years old and probably able to communicate subjective data point inquiries. Subjective data collection for the eye includes onset, quality, location, severity, precipitating factors, related symptoms, and alleviating factors. The patient should be asked by the clinician if she was near sand and when the sensation of sand started. The patient should be asked whether she experiences discomfort in a particular area of her eye, how severe the pain is, whether there are any visual abnormalities, blurriness, or loss of vision, and whether there is anything that eases the irritation or sand-like feeling (Rhoades and Peterson, 2021). In addition, I would like to know if the eye is hurting or merely itching. I would ask the patient to rate the intensity of any reported pain on a scale of 0 to 10. Regarding causative causes, I would inquire. I would like to know whether there has been any harm to the eye or if it has come into contact with foreign objects. I would also inquire about any related symptoms, including changes or eye sight loss.

Additional Objective Data

According to Rhoades and Peterson (2021), objective data collection of the eye includes a basic fundoscopic examination without pupil dilation, corneal reflex measurement, palpation, and inspection. During the examination, the healthcare professional would check for redness and edema on the lids, feel for extra exudate on the lower lid, and assess the color and consistency of the fluid. The provider should check for foreign bodies by evertting the upper lid. To check for foreign objects, retinal exudate, and background hemorrhages or lesions, the healthcare professional would utilize a fundoscope.

Diagnostic Exams

The practitioner should swab the eye and order a culture to check for bacterial infection, even though the patient may have described a foreign body or an allergic reaction (Delugash & Story, 2021).

Differential Diagnosis and Rationale

There are three possible differential diagnoses for this patient: bacterial conjunctivitis of the left eye, allergic conjunctivitis of the left eye, or a foreign body in the left eye. No matter the cause of the initial onset, the patient's inability to open her eyes in the morning because of crusted exudate is probably a sign that the conjunctivitis may not be allergic and has now developed into a bacterial infection (Delugash & Story, 2021).

The first differential diagnosis based on the patient's symptoms is a foreign body in the left eye. The diagnosis of allergic conjunctivitis of the left eye may be made since the symptoms are similar and include itching, clear watery discharge, and redness of the sclera, conjunctiva, and occasionally the lids (Dupuis et al., 2020). Despite the patient's denial of any allergy history, environmental allergies may develop in her at this age based on potential new exposures. Redness of the sclera, conjunctiva, and occasionally lids, itching, and crusty or pus-like discharge that frequently has a yellow or green tint are the symptoms of bacterial conjunctivitis (Delugash & Story, 2021).