(SOLUTION) NR511 Week 3: Clinical Case Study Part Two Discussion

Now, assume that any procedures and/or testing which were performed are NORMAL.

1. What is your primary (one) diagnosis for this patient at this time? (support the decision for your diagnosis with pertinent positives and negatives from the case)

2. Identify the corresponding ICD-10 code.

3. Provide a treatment plan for this patient’s primary diagnosis which includes:

  • Medication*
  • Any additional testing necessary for this particular diagnosis*
  • Patient education
  • Referral

4. Provide an active problem list for this patient based on the information given in the case.

5. Are there any changes that you would also make to this patient’s overall treatment plan at this time? Must provide an EBM argument for each treatment or testing decision.

6. Provide an appropriate F/U plan.

*If part of the plan does not warrant an action, you must explain why. ALL medication and testing decisions (or decisions not to treat with medication or additional testing) MUST be supported with an evidence-based medicine (EBM) argument. Over-the-counter (OTC) and RXs must be written in full as if handing a script to the patient in the office.

Participation Guidelines

Enters initial post to part one by 11:59 p.m. MT on Tuesday; initial post to part two by 11:59 p.m. MT on Thursday; responds substantively to at least one topic-related post of a peer including evidence from appropriate sources in parts one and two, AND all direct faculty questions in parts one and two by Sunday, 11:59 p.m. MT.

SOLUTION

Diagnosis: Allergic Conjunctivitis

In respect to this particular case study, the main diagnosis being offered is Allergic Conjunctivitis. The clinical symptoms and signs of ocular allergy are quickly recognized as well as include itching, tearing, conjunctiva hyperaemia, photophobia, then chemosis (Leonardi, et al., 2015). A lot of these pertinent positive signs is included by the patient. The sole indicator because of this list the in-patient is lacking is chemosis of the eyes. Because of regular findings, by staining of the eyes rules out the corneal ulcers or abrasions. The coryza noted towards the patient’s nose with well-defined drainage is actually an allergic reaction to an allergen or perhaps pollutant. The coryza is induced by degranulation of the mast cells in the nose. Pollen is among the most regular triggers of sensitive conjunctivitis; observing this’s smoke and pollutants (Leonardi, et al., 2015). This particular in-patient exposes himself to smoke by taking part in recreational use of marijuana.

ICD: ICD ten code for the examination of Allergic Conjunctivitis is H10.45.

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