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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. Physical assessment essentially negative with the exception of noted pale and boggy nasal turbinate’s as well as mild to moderate swelling and clear drainage. Bilateral eyes with noted photosensitivity and diffuse conjunctiva redness and tearing. Visual acuity remains 20/20 bilaterally (uncorrected), no foreign object noted, no mass, lesions or crusting on lids. Fundiscopic examination WNL. Differential Diagnoses: -Allergic conjunctivitis is caused by a type I immune response to an allergen. The allergen binds to a mast cell and crosslinking to IgE occurs, leading to mast cell degranulation and initiation of an inflammatory cascade (Leonardi, Castegnaro, Valerio &Lazzarini, 2015). This results in release of histamine from mast cells, as well as other mediators, including tryptase, chymase, heparin, chondroitin sulfate, prostaglandins, thromboxane, and leukotrienes. Histamine and bradykinin immediately stimulate nociceptors, resulting in itching, increased vascular permeability, vasodilation, redness, and conjunctival injection (Leonardi, Castegnaro, Valerio & Lazzarini, 2015). -Viral/Infective conjunctivitis occurs as a result of reduced host defenses and external contamination. Infectious pathogens can invade from adjacent sites or by a blood-borne pathway and replicate within the conjunctival mucosal cells (Epocrates, 2018). Both bacterial and viral infections initiate a leukocyte or lymphocytic inflammatory cascade leading to the attraction of red and white blood cells to the area. These white blood cells reach the conjunctival surface and accumulate there by easily moving through the dilated and highly permeable capillaries (Leonardi, Castegnaro, Valerio & Lazzarini, 2015). -Dry eye disease (DED) is a multifactorial ocular surface disease characterized by a loss of homeostasis of the tear film due to tear film hyperosmolarity and instability, ocular surface inflammation and damage, and neurosensory abnormality. This results in ocular discomfort, dryness, and visual disturbance (Epocrates, 2018). Rank the Differential -Allergic conjunctivitis – patient also has history of seasonal allergies that relieves by oral antihistamine, which he has not been taking. -Viral Conjunctivitis -Dry eye Disease
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Additional Testing and Procedures: -No testing or procedure needed at this time since patient is suspected to have allergic conjunctivitis.
Epocrates Athena Health. (2018). Epocrates Drug. Retrieved from https://online.epocrates.com/drugs Leonardi, A., Castegnaro, A., Valerio, A., Lazzarini, and D. (2015).Epidemiology of allergic conjunctivitis: clinical appearance and treatment patterns in a population based study. Allergy and Clinical Immunology, 15(5). 482-488. https://doi: 10.1097/ACI.0000000000000204 This study source was downloaded by 100000805705997 from CourseHero.com on 12-09-2021 21:19:52 GMT -06:00
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ICD10.Diagnosis codes. (2018). Retrieved from http://www.icd10data.com Seidman, M., Gurgel, R., Lin, S. (2015). Allergic rhinitis: clinical practice guideline. Otolaryngology-Head and Neck Surgery, 152(1) S1-S43. https://doi.org/10.1177/0194599814561600
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.
is ar stu ed d vi y re aC s o ou urc rs e eH w er as o. co m
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.
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Primary Diagnosis is allergic conjunctivitis (H10.45) using International Classification of Diseases (ICD) code 10 (ICD10, 2018). All forms of allergic conjunctivitis are bilateral. The condition is usually associated with a watery or ropy mucoid discharge, and itching must be present as the primary complaint to make the diagnosis (Epocrates, 2018). Allergic conjunctivitis is most commonly seasonal and often associated with patients with a history of atopic dermatitis, hay fever, and asthma. I would prescribe the following medications at this time: Loratadine (Claritin) 10 mg Disp# 30 Sig: 1 Tab by mouth daily RF: PRN This study source was downloaded by 100000805705997 from CourseHero.com on 12-09-2021 21:19:52 GMT -06:00
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Fluticasone Nasal Spray (Flonase) 50mcg per actuation Disp# 1 unit (oz) Sig: 1 puff in each nostril BID (max of 2 puffs/actuations in each nostril/day) RF: PRN Visine-A (pheniramine/naphazoline) Opthalmic Solution OTC. Disp# 0.5 oz Sig: 1-2 gtts each eye Q6H PRN. (Do not use more than 2 weeks) RF: PRN
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Other than a HEENT exam, visualizing the ocular nerve and discs, 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. Monitoring If the patient with acute conjunctivitis does not improve over 7 to 10 days, or reports persistent decreased visual acuity or light sensitivity, refer to an eye specialist for consultation (Pflipsen, Massaquoi & Wolf, 2016). I would ask him to call if his condition does not subside or worsen in 3-5 days, and have him return for a cell culture (bacterial or viral isolation) (Dunphy, 2015), or more in-depth diagnostic tests, depending on his presentation at that time. Patient Instructions
Active problem list
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-If you have conjunctivitis that is caused by an allergy, try to stay away from the things you are allergic to. Try not to touch your eyes or rub your eyes with your fingers. - Conjunctivitis that is caused by viruses or bacteria can be spread from person to person. It is important to wash your hands with soap often during the day. -Advice regarding strict hand washing and not sharing any towels or bedding may help prevent spread of infection. Typically, viral conjunctivitis is contagious until the eye is no longer red and tearing. - He will also need to be reminded to clean his sheets and replace his pillows frequently or to purchase a hypoallergenic to decrease exposure to dust/mold. -Also inform the patient that he may get eye irritation from overuse of electronic devices, he should take breaks when reading or working on computer or other electronic devices. -If there is any immediate concern I would remind him to utilize the emergency department.
-Recreational use of marijuana - with regard to exposure to the drug itself and smoke could exacerbate his allergies as well as cause eye irritation. -Alcohol consumption - drinks 3-6 beers per weekend. Possible interactions with anti-histamine -Seasonal allergic rhinitis with springtime triggers - being in a different location that has different types of seasonal pollen or grass. - Adopted, does not know biological parents history
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