Week 3: Clinical Case Study Part Two Discussion

Week 3: Clinical Case Study Part Two Discussion Student chooses one appropriate diagnosis for the patient. What is your primary (one) diagnosis for this patient currently? (support the decision for your diagnosis with pertinent positives and negatives from the case) My primary diagnosis of this 19-year-old male patient would be Allergic Conjunctivitis Diagnosis is supported with strong pertinent data. a. Positive data- Patient had a sudden onset of 2 to 3 days which confirms diagnosis of spring allergies, eye redness, itching, tearing, FM sensation and feels his eyes are gritty. b. Negative data- Patient did not have a fever or report feeling ill. Patient also denied drainage from his eyes. Patient did not have sneezing. ICD-10 Code H10.13, Acute atopic conjunctivitis bilateral Treatment plan for primary diagnosis included medication, additional testing, patient education. Loratadine 1 tablet by mouth daily- education-Loratadine is an antihistamine that reduces natural chemicals called histamines in the body. Used to treat allergy symptoms. Should not take this medication if allergic to Clarinex. (Epocrates Atehna Health 2018) Fluticasone nasal spray 1 spray in each nostril daily, Education- Medication is used to treat seasonal allergies. (Epocrates Atehna Health 2018) Pataday 0.1% instill 1 d