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.
Solution
Week 3 Clinical Case Study Part Two Discussion
Primary Diagnosis:
The primary diagnosis in the case of this patient is allergic conjunctivitis. With a previous history of seasonal allergies, this likely points to allergic conjunctivitis. The patient reports that he is not currently taking the two allergy medications (fluticasone and loratadine). The patient is experiencing rhinorrhea and intermittent nasal congestion. The presentation of itchy eyes, foreign body sensation ‘like sand”, redness and tearing all point towards an allergic mechanism. The patients’ physical examination findings also report pale boggy turbinates with some swelling and clear drainage. The negative pertinent also include no purulent drainage to his eyes. The bilateral symptom occurrence in this patient points more towards allergic conjunctivitis rather…………………please follow the link below to purchase the solution at $5
