The Assignment:
After reviewing the case and the accompanying case analysis questions, included in the document, answer the questions directly in a word document. When providing evidence to support your answers, be sure they evidenced-based, current (no more than 5 years old), and follow current standards of care. Follow APA 7th edition formatting, including a cover page and references.
Mr. Raymond Jackson is a 68-year-old who is in the office today, on Monday, complaining of right eye pain. He states this started rather suddenly over the weekend. He has redness, itching, burning along the edge of his right eye lid. He reports no trauma, he thinks it started while he was sleeping Saturday night. Otherwise, he is in fair health, he has a history of Diabetes type 2, hypertension, hyperlipidemia and seborrheic dermatitis which he has seen a dermatologist for in the past. He still works part time as a school crossing guard at the neighborhood elementary school. He has been a widower for 2 years and he has 3 children who live out of the area. He worked for many years in construction, until the work
became more physically demanding. He has social security, and his medical coverage is through a Medicare Advantage plan, he does not qualify for Medicaid in his state. VS: BP 138/84 Pulse 88 Resp 18 Temp 97.8 02 Sat 96% Ht 70 inches Wt 190 lbs PMH: As stated in case presentation, also history of chronic low back pain. Allergies: NKDA Medications:
Glucophage 500mg 1 po BID
Metoprolol 25mg po daily Lisinopril 10mg po daily
Atorvastatin 20mg po daily
Ibuprofen 200mg 2 po very 6 hours as needed for back pain Social History: As described in case presentation. Also, he lives independently in a small apartment; he doesn’t know his neighbors very well but has some close friends from his old neighborhood. He uses public transportation to shop, visit friends and get to his medical appointments. He does not smoke, does not drink alcohol. ROS: Back pain today 2/10, right eye itching, feels like his right eye is very dry. Diagnostics/Assessment: Last HgA1c, 2 months ago, was 6.5
ANSWER THESE QUESTIONS:
1. What is the likely diagnosis of Mr. Jackson’s eye issue? List 3 differentials as well.
2. What are some contributing factors for your diagnosis? List 3 contributing factors.
3. What physical examination and diagnostic tests would you complete for Mr. Jackson at this visit?
4. Describe your treatment plan for this visit, including any follow up or referrals.
5. What Social Determinants of Health (SDOH) would you include in your plan?
6. Briefly describe a Medicare advantage plan.
I have upload the Soap templete to be used as an attachment.
