[##]-year-old [male/female] with history and exam consistent with corneal
abrasion of the [right/left] eye.
Initial considerations in
this patient included corneal abrasion, intraocular and corneal foreign bodies,
corneal ulceration, various etiologies of iritis, and various etiologies of
conjunctivitis amongst others.
Patient presented with eye
pain and redness with associated [photophobia, foreign body sensation, and
decreased visual acuity] in the setting of recent [describe injury] suggestive
of corneal abrasion. Patient noted to
have corneal abrasion on fluorescein examination with [slit lamp/wood’s lamp]
of the [right/left] eye. No evidence of
foreign bodies with eversion of the [right/left] eyelid. Patient [reports/denies] contact lens use,
and has no other findings suggestive of corneal ulceration at this time. No evidence of a positive Seidel test or
other findings suggestive of globe perforation on evaluation in the ED. No evidence of corneal foreign body on
exam.
Significant improvement in
pain and visual acuity noted with application of topical anesthetic to the
eye. Prior to
discharge, we discussed return precautions, treatment with lubricating eye
drops and NSAIDs, and follow up with primary care doctor within 1 week as
needed for further evaluation, and the patient demonstrated understanding and
agreement.
EXCELLENT SUMMATION. I would only add no evidence of globe rupture
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