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? (support the decision
for your diagnosis with pertinent positives and negatives from the case)
Identify the corresponding ICD-10 code.
Provide a treatment plan for this patient's primary diagnosis which includes:
Any additional testing necessary for this particular diagnosis*
Referral and follow-up to the treatment plan
Provide an active problem list for this patient based on the information given in the
*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
The established primary diagnosis for the patient is allergic conjunctivitis as supported by the presenting symptoms, physical examination, and history. The patient moved to a new state, is experiencing new living environment new weather, and seasons. The patient has a history of seasonal allergic rhinitis in spring season, rendering him more vulnerable to atopy. More so, the patient has pale boggy nasal turbinate with clear nasal drainage with mild-moderate swelling and clear nasal drainage, which all indicate allergies. The patient denies a recent history of URI and no mucoid drainage or lymphadenopathy observed through physical exam, rendering viral conjunctivitis a less probable diagnosis. Dry eye syndrome is usually more chronic in nature so its diagnosis cannot be concluded only after 2 to 3 days of the clinical presentations (Aremu, Ibrahim, Ibrahim, & Ajoke, 2019).
Pertinent Positive Findings: bilateral eye involvement, foreign body sensation, sensitivity to light, diffuse conjunctival redness, tearing, itching, pale and boggy nasal turbinates with swelling, runny nose, intermittent nasal congestion, symptoms lasting 2 to 3 days, clear nasal drainage, vision acuity 20/20, pupils PERRLA, no lymphadenopathy (Aremu et al., 2019)…Please click the icon below to purchase the full solution at $5