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The role of a clinician who is building a health history

 

 

 

take on the role of a clinician who is building a health history for one of the following cases.
Chief Complaint
(CC) : 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.”
Subjective: 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
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.

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