[##]-year-old [male/female] with [eye redness/irritation] with history and
exam consistent with likely allergic 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, [itching, watery discharge, matting]
and eyelid swelling suggestive of allergic conjunctivitis. Patient denies purulent discharge, and has no
other on exam suggestive of bacterial etiologies for 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] a history
of seasonal allergies [with/without] associated [nasal congestion/rhinorrhea]. Patient noted to have no significant decrease
in visual acuity at this time.
Prior to discharge, we discussed return precautions, treatment with
topical eye drops and [anti-histamine/antibiotic ointment/NSAIDs], and follow
up with primary care doctor within 1 week as needed for further evaluation, and
the [patient/patient’s mother/father/parents] demonstrated understanding and
agreement with this plan.
This comment has been removed by the author.
ReplyDelete