Differential Diagnosis and Primary Care Paper

Primary Diagnoses

From the history and physical examination findings, my primary diagnosis for this patient is seasonal conjunctivitis. From the history, the presenting complaints are typical of conjunctivitis (Azari & Barney, 2013). Gritty sensation or feeling of foreign body-sand inside the eye, tearing, itching, and redness are classical symptoms of conjunctivitis. However, there is no history of purulent discharge which is an important negative since it rules out the possibility of bacterial conjunctivitis. This means that the possible conditions so far include viral or allergic conjunctivitis Differential Diagnosis and Primary Care Paper.

Without a doubt the history and physical examination does not rule in viral conjunctivitis. There is a history of an ongoing infectious process that could suggest viral conjunctivitis. However, the presentation strongly suggests seasonal allergic conjunctivitis. The patient has a history of nasal allergies which is worse during spring. This indicates that the patient is suffering from seasonal allergic conjunctivitis which is associated with nasal allergies (La Rosa et al., 2013. Seasonal allergic conjunctivitis corresponding ICD-10 code is ICD-10-CM H10.45.

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Medications

Primary treatment of allergic conjunctivitis is avoidance of offending agent afterwards, secondary interventions can be instituted. Secondary interventions include the use of pharmacologic agents which are of different classes used to alleviate the symptoms (Leonardi, et al., 2015). Artificial tears provide barrier function and activates the immune defense mechanism of the conjunctiva Differential Diagnosis and Primary Care Paper.

Antihistamines such as certizine can be used to alleviate the acute symptoms which arise due to the binding of histamine to its receptors on the ocular surface which has the effect of intensifying inflammation. To relieve short-term injection and redness of the eye, vasoconstrictors along with histamines can be used. An example of vasoconstrictor includes phenylephrine. Mast cell stabilizers can also be prescribed to reduce its inflammatory effect. Mast cells stabilizers prevent the degranulation of mast cells decreasing the release of histamine and other chemotactic factors. An example of mast cells stabilizer drug is alomide.

Nonsteroidal anti-inflammatory drugs can also be sued which inhibits the cyclooxygenase metabolic pathway and inhibit mediators of inflammation such as prostaglandins and thromboxane (Leonardi, et al., 2015). Corticosteroid such as fluticasone can also be used since, generally, corticosteroids have an anti-inflammatory action.

Patient Education

The patient information should focus on allergens avoidance, the symptoms, and medications as well as adherence. The patient should be educated on the cause of the allergy as well a measures to prevent allergies such as avoiding allergens such pollen grains or anything else that provoke the symptoms (Leonardi, et al., 2015). The symptoms presented above should be made clear to the patient that it is arising. The prescribed medications should be explained in details, the dosage, and regimen.

Referral

A multidisciplinary team in healthcare delivery is associated with positive patient outcomes. Therefore, referral to a specialist where the patient can benefit is crucial. A referral to a specialist immunologist should be considered. An immunologist who has super-specialized in allergy immunology will play an important role in the management of this patient. Additionally, a referral to an ophthalmologist should be considered Differential Diagnosis and Primary Care Paper.

Active Problem list

Nasal congestion
Gritty, tearing and red eyes
Follow-up plan

Follow-up plan for this patient is directed at monitoring for adherence to medication as well patient education guidelines. Additionally, the patient should be seen every two weeks at an ophthalmology clinic to asses for possible systemic complications or a superimposed bacterial infection.

References

Azari, A. A., & Barney, N. P. (2013). Conjunctivitis: a systematic review of diagnosis and treatment. Jama, 310(16), 1721-1730.

La Rosa, M., Lionetti, E., Reibaldi, M., Russo, A., Longo, A., Leonardi, S., … & Reibaldi, A. (2013). Allergic conjunctivitis: a comprehensive review of the literature. Italian journal of pediatrics, 39(1), 18.

Leonardi, A., Castegnaro, A., Valerio, A. L. G., & Lazzarini, D. (2015). Epidemiology of allergic conjunctivitis: clinical appearance and treatment patterns in a population-based study. Current opinion in allergy and clinical immunology, 15(5), 482-488 Differential Diagnosis and Primary Care Paper.

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