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
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller VEVA2K. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for £15.16. You're not tied to anything after your purchase.
