MDM - Viral Conjunctivitis

[##]-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.