NR 511 Week 3 Case Study Discussion Part 2
Now, assume that any procedures and/or testing which were performed are NORMAL.
In Part 2 you might be … some additional history, exam or test findings. Using this information and the information in Part 1, answer the following questions:
What i...
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.
Primary Diagnosis is allergic conjunctivitis (H10.45) using International Classification of Diseases (ICD) code 10 (ICD10,
2018). All forms of allergic conjunctivitis are bilateral. Symptoms of allergy-related conjunctivitis include intense
itchiness and string-like, mucusy, clear, or white discharge. (Epocrates, 2018). Allergic conjunctivitis, which is not
contagious, occurs when the conjunctiva has an inflammatory response to certain allergens, such as pollen, dust, mold,
pet dander and cigarette smoking. An exposure to these allergens causes the body to release a chemical called
histamine, which causes the symptoms we see the patient presents with redness, tearing, and itching in the eye. This
also can be a seasonal allergy response to certain things in the environment for many patients.
Medication prescription:
Loratadine (Claritin) 10 mg
Disp# 30
Sig: 1 Tab by mouth
This study source was downloaded by 100000834430951 from CourseHero.com on 01-21-2022 10:51:45 GMT -06:00
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