[##]-year-old [male/female] with [eye redness/irritation] with history and
exam consistent with likely viral conjunctivitis.
Initial considerations in
this patient included viral, bacterial, and allergic etiologies of
conjunctivitis, corneal abrasion, corneal ulceration, and iritis among others.
Patient presented with
complaint of red eye with associated irritation and watery discharge suggestive
of viral conjunctivitis. Patient [reports/denies]
contact lens use or purulent discharge, and has no other findings suggestive of
bacterial etiologies of conjunctivitis.
Patient noted to have [no/punctate] uptake of fluorescein on [slit
lamp/wood’s lamp] examination of the [right/left] eye. Patient [reports/denies] recent upper
respiratory symptoms [consistent with viral etiology of conjunctivitis]. Patient [reports/denies] associated itching with
no evidence of swelling or irritation of the eyelids to suggest allergic
etiology of conjunctivitis. Patient
noted to have no significant decrease in visual acuity in the ED.
Prior
to discharge, we discussed return precautions, treatment with topical eye drops
[and antibiotic ointment/NSAIDs], and follow up with primary care doctor within
[2-3 days/one week] for further evaluation, and the [patient/patient’s
mother/father/parents] demonstrated understanding and agreement with this plan.
