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
Based on the presenting symptoms reported by the patient of both eyes being affected, gritty, sand like sensation, redness, tearing, itching, rhinorrhea, history of seasonal allergies, recreational marijuana use and the physical assessment findings of bilateral conjunctiva with diffuse redness and tearing, slight photophobia, nasal turbinates that are pale and boggy with mild to moderate swelling, nasal drainage that is clear, my diagnosis of this patient is allergic conjunctivitis. Due to the characteristics of the drainage from bilateral eyes and report of not recently being ill. Testing his visual acuity and performing a thorough exam of his eyes was also pertinent in coming to this diagnosis….Kindly click the purchase icon to purchase the full solution at $10