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NR 511 Week 3 Case Study Discussion: Part Two
Now, assume that any procedures and/or testing which were performed are NORMAL.
What is your primary (one) diagnosis for this patient at this time?
Identify the corresponding ICD-10 code.
Provide a treatment plan for this patient's primary diagnosis which includes:
o Medication*
o Any additional testing necessary for this particular diagnosis*
o Patient education
o Referral and follow-up to the treatment plan
Provide an active problem list for this patient based on the information given in the case.
*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
Answer:
Week 3 Part 2
Addition to part 1 submission.
Other than visualizing the eyes and performing a vision test. Further diagnostic testing is not necessary
at this juncture since the patient is not reporting any vision abnormality and no foreign object was noted
on the fundoscopic exam. If further irritation or worsening occurs I would suggest a referral to an
ophthalmologist where they can perform a more in depth exam as well as other available diagnostic
screenings. I would however screen for allergens or IgE molecules to determine the causative factors by
both blood and skin testing (Maris, 2017).
In addition to causes of allergic conjunctiva; mast cells cause histamine to be released from the
aggravating allergen thus causing the presented symptoms (Maris, 2017).
Primary Diagnosis is allergic conjunctivitis (H10.45) with concurrent allergic rhinitis (J30.9) using
International Classification of Diseases (ICD) code 10 (ICD10, 2018). These diagnoses were chosen since it
can explain the majority of his presenting symptoms of nasal congestion, with reddened turbinate’s,
itchy watery eyes as well as feeling as there is a foreign object bilaterally. Allergic conjunctivitis and
allergic rhinitis generally go hand and hand when there is an exposure to allergens (Akerman, Smith &
Gomes, 2016).
This study source was downloaded by 100000839739811 from CourseHero.com on 03-19-2022 11:31:54 GMT -05:00
https://www.coursehero.com/file/57423812/NR-511-Week-3-Clinical-Case-Study-Part-Two-Discussiondocx/
NR 511 Week 3 Case Study Discussion: Part Two
Now, assume that any procedures and/or testing which were performed are NORMAL.
What is your primary (one) diagnosis for this patient at this time?
Identify the corresponding ICD-10 code.
Provide a treatment plan for this patient's primary diagnosis which includes:
o Medication*
o Any additional testing necessary for this particular diagnosis*
o Patient education
o Referral and follow-up to the treatment plan
Provide an active problem list for this patient based on the information given in the case.
*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
Answer:
Week 3 Part 2
Addition to part 1 submission.
Other than visualizing the eyes and performing a vision test. Further diagnostic testing is not necessary
at this juncture since the patient is not reporting any vision abnormality and no foreign object was noted
on the fundoscopic exam. If further irritation or worsening occurs I would suggest a referral to an
ophthalmologist where they can perform a more in depth exam as well as other available diagnostic
screenings. I would however screen for allergens or IgE molecules to determine the causative factors by
both blood and skin testing (Maris, 2017).
In addition to causes of allergic conjunctiva; mast cells cause histamine to be released from the
aggravating allergen thus causing the presented symptoms (Maris, 2017).
Primary Diagnosis is allergic conjunctivitis (H10.45) with concurrent allergic rhinitis (J30.9) using
International Classification of Diseases (ICD) code 10 (ICD10, 2018). These diagnoses were chosen since it
can explain the majority of his presenting symptoms of nasal congestion, with reddened turbinate’s,
itchy watery eyes as well as feeling as there is a foreign object bilaterally. Allergic conjunctivitis and
allergic rhinitis generally go hand and hand when there is an exposure to allergens (Akerman, Smith &
Gomes, 2016).
This study source was downloaded by 100000839739811 from CourseHero.com on 03-19-2022 11:31:54 GMT -05:00
https://www.coursehero.com/file/57423812/NR-511-Week-3-Clinical-Case-Study-Part-Two-Discussiondocx/
