Subjective: Patient presents with complaints consistent with Sicca Syndrome, including dry eyes (xerophthalmia), dry mouth (xerostomia), and difficulty swallowing.  Symptoms include ocular burning, itching, foreign body sensation, photosensitivity,  oral dryness, difficulty with chewing and speaking, altered taste, and increased dental caries.  Patient reports these symptoms have been ongoing for several months and are progressively worsening, impacting quality of life.  Review of systems reveals potential systemic symptoms including fatigue, joint pain, and skin dryness.  Past medical history includes hypothyroidism, for which the patient takes levothyroxine.  Medications also include over-the-counter artificial tears and saliva substitutes, which provide minimal relief.  Family history is negative for autoimmune disorders.  Social history is non-contributory.

Objective:  On examination, ocular findings include conjunctival injection, decreased tear film, and positive Schirmer's test results indicative of reduced tear production.  Oral examination reveals dry, sticky mucosa, fissured tongue, and evidence of dental caries.  No palpable salivary gland enlargement is noted.  Vital signs are stable.  Preliminary differential diagnoses include Sjogren's Syndrome, age-related dryness, medication side effects, and other autoimmune connective tissue diseases.

Assessment: Based on the patient's symptoms, clinical findings, and diagnostic criteria, the diagnosis of Sicca Syndrome is suspected.  Further investigation is warranted to differentiate Sicca Syndrome from Sjogren's Syndrome and other potential causes.  This may include serological testing for autoantibodies (anti-RoSSA, anti-LaSSB), salivary gland biopsy, and consultation with rheumatology.

Plan:  The patient was educated on Sicca Syndrome, its potential causes, and management strategies.  Recommendations include increasing fluid intake, using lubricating eye drops and oral moisturizers, practicing good oral hygiene, and avoiding environmental irritants.  A prescription for pilocarpine ophthalmic solution was provided to stimulate tear production.  Referral to ophthalmology and rheumatology is scheduled for further evaluation and management of dry eyes and potential underlying autoimmune disease.  Follow-up appointment is scheduled in four weeks to reassess symptoms and review laboratory results.  Patient education materials on Sicca Syndrome and Sjogren's Syndrome were provided.  ICD-10 code M35.0 (Sicca Syndrome) is used for billing purposes.  CPT codes for the evaluation and management visit, Schirmer's test, and consultations will be documented appropriately.