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Below, you will be presented with a patient case situation. After reviewing the patient case, answer the following questions listed.
What differential diagnoses are you considering?
What abnormals are observed from the diagnostic tests, and what are your interpretations?
What evidence-based treatment plan are you considering?
It is important to note that the only problems the patients in the case studies have been identified. This means if it is not stated you can assume it is normal and you should describe what you would expect normal to be as applicable in your post. Each portion of the case study should be written as you would in a Focus SOAP note (an example of a SOAP note was shared in the Week 01 tips tab.
A 55-year-old male presents to the clinic with a chief complaint of painful, red, left eye. He states that “both eyelids are sticking together”. He complains of nasal congestion for 3 days and is taking triprolidine and pseudoephedrine. He also states that he began self-treating with sulfacetamide eye drops that he used with a previous eye infection 2 days ago. His past medical history revealed hypertension for 20 years and an eye infection 2 years ago. He states his hypertension has been well controlled until this visit. His wife died 6 months ago and he lives alone. He denies any use of tobacco but does drink alcohol occasionally. He has an allergy to Penicillin (causes rash).
Current Medications-
Triprolidine and pseudoephedrine, 2 tables PO QID X 2 days
Hydrochlorothiazide, 25 mg PO QD
Sulfacetamide eye drops, 2 drops both eyes Q6h X 2 days
Potassium chloride tablets, 10 mEq 2 tablets PO BID (states he stopped taking it several months ago)
His physical exam revealed a well-groomed male, slightly male malnourished and dehydrated; left eye is red with purulent discharge accumulated on the lashes. His vital signs are BP 155/96 and HR 65 supine, BP 130/80 and HR 100 standing, RR 23, T 98.9 F, Wt. 125.6 lbs, Ht 6 ft 2 inches. He is in sinus tachycardia. EENT exam revealed left eye brilliant red in appearance, more intense at limbus, mucopurulent discharge; right eye marginally red; both eyelids swollen; no evidence of trauma, but a well circumscribed gray lesion can be seen with fluorescein stain. Pupils react mildly to light, slightly dilated.
Labs were drawn as well as a conjunctival swab. Results are below.
Na 144, K 3.0, CL 85, HCO3 30, Bun 14, Cr 1.7, Hct 0.44, Hgb 23, Lkcs 11.4 X 109, Plts 350 X 109, Glu 101, LFT: Normal, CXR: Normal
Conjunctival swab: Gram’s stain: gram-positive lancet-shaped cocci in pairs; culture and sensitivities pending.
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