NR 511 > Week 3 Case Study Discussion Part 1 & 2; Chamberlain College of Nursing ( Latest) Graded A

NR 511. Week 3 Case Study Part 1 Patient is a 19 year old Male who presents today with a complaint of bilateral eye discomfort that began 2-3 days ago. The eye discomfort is reported as a 2/10 on the pain scale and is described as a constant “gritty” or sand like feeling. He further reports his eyes are itchy and have watery drainage or tearing. He reported having redness that temporary relieved with OTC visine, but the eye irritation continued. The patient does not recall any recent trauma or foreign object in his eyes. He denies any crusting or purulent drainage. He does note that he has an occasional runny nose with intermittent congestion but no sneezing. His past medical history includes seasonal nasal allergies which flares up only in spring and is controlled with Loratadine 10mg and Fluticasone Nasal Spray in peak season. The patient further denies any ear pain, throat pain or redness, fever, chills, SOB or wheezing. Week 3 Part 2 Addition to part 1 submission. 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.