nr511 case study part 2.docx - 1 Diagnosis Allergic Conjunctivitis Bilateral Pertinent positives Sudden onset of bilateral red itchy tearing eyes along

nr511 case study part 2.docx - 1 Diagnosis Allergic...

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1.) Diagnosis Allergic Conjunctivitis, Bilateral Pertinent positives: Sudden onset of bilateral red, itchy, tearing eyes, along with a sensation of a FB, red conjunctiva, clear rhinitis, nasal turbinates are pale and boggy with inflammation, history of seasonal allergies with effective treatment of Loratadine and Fluticasone. Pertinent negatives: No fever, pain, cough, FB’s, change in visual acuity, no purulent or mucoid drainage, corneal abrasion, subconjunctival hemorrhage lymphadenopathy, or any unilateral eye complaints. 2.) . The ICD-10 code for this diagnosis is: H10.13 Acute atopic conjunctivitis, bilateral 3.) . Treatment plan: A treatment plan should be personalized to the patient’s age, current symptoms and their past medical history. Allergic conjunctivitis has no established parameters. Because he has had efficacious results with Loratadine and Flonase, this treatment should be continued with the addition of a topical antihistamine like Emadine per EBM. Topical antihistamines and mast cell stabilizers, either alone or in combination, are safe and effective for reducing the symptoms of seasonal and perennial allergic conjunctivitis. (Mounsey, et al., 2016).
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