NR 511 /NR 511 Week 3 Part 2 Case Study

Week 3 Part 2 Addition to part 1 submission. Other than visualizing the eyes 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. If further irritation or worsening occurs | would suggest a referral to an ophthalmologist where they can perform a more in depth exam as well as other available diagnostic screenings. | would however screen for allergens or IgE molecules to determine the causative factors by both blood and skin testing (Maris, 2017). In addition to causes of allergic conjunctiva; mast cells cause histamine to be released from the aggravating allergen thus causing the presented symptoms (Maris, 2017). Primary Diagnosis is allergic conjunctivitis (H10.45) with concurrent allergic rhinitis (J30.9) using International Classification of Diseases (ICD) code 10 (ICD10, 2018). These diagnoses were chosen since it can explain the majority of his presenting symptoms of nasal congestion, with reddened turbinate’s, itchy watery eyes as well as feeling as there is a foreign object bilaterally. Allergic conjunctivitis and allergic rhinitis generally go hand and hand when there is an exposure to allergens (Akerman, Smith & Gomes, 2016). Active problem list can include use of marijuana with regard to exposure to the drug itself and smoke could exacerbate his allergies as well as cause eye irritation. Other factors include being in a different location that has more seasonal allergens such as pollen or grass.