Subjective Data
Chief Complaint (CC)
The patient expresses concerns about his right eye. He reports having an itching and burning sensation in his right eye. Moreover, he says that the eye produces more liquid than usual, and the patient often wakes up with a crusty eyelid.
History of Present Illness (HPI)
The patient is male. He is thirty-four years old. The patient wears contact lenses due to having myopia. However, there is no known history of him having any other diseases connected to eyesight problems. The main complaints of the patient include redness and itchiness of the conjunctiva of the right eye, increased tear production and presence of liquid discharge in the eye. Moreover, he reports to having problems with wearing his contact lenses. The right eye started to itch and burn three days ago. The patient tried to clean the eye with water and searched for any foreign objects that might have caused the irritation. Then, the patient applied Visine eye drops, which temporarily soothed the irritation. However, the redness did not go away. The left eye seems to look healthy. The patient reports to having good hygiene and says that he washes hands regularly.
Allergies
NKDA
Past Medical History
The patient was diagnosed with myopia when he was twelve years old. He usually wore glasses. However, he decided to switch to contact lenses a month ago.
The patient has no history of other diseases connected to eyesight. No previous history of eye infections is recorded.
Family History
The patient denies having any family history relevant to his condition. The father has a history of regulated hypertension. He takes medications and performs regularly check-ups at the hospital. The mother has a history of a generalized anxiety disorder, which is being treated with therapy. She was diagnosed with GAD a year ago. No medical history related to eye diseases can be found.
Surgery History
The patient has no history of major surgeries.
Social History
The patient admits to smoking and drinking on rare occasions. He denies illicit drug use. The patient lives with his wife and daughter. He works as a professor at a university. He denies having stressful experiences at work. He does not exercise regularly due to a busy schedule. His safety level is average. However, the history of hypertension and mental illness in his family should be considered in the future.
Current Medications
The patient denies taking any medications.
Review of Systems
General: The patient denies having any recent body problems or weight fluctuation. He has a normal appetite and sleeps as usual. The levels of energy are regular as well.
Cardiovascular: The patient denies any chest pains, palpitations, edema, or dyspnea.
Respiratory: The patient reports having no problems with breathing. He denies asthma or coughing.
Dermatology: The patient denies having any skin problems. However, he reports to having redness and irritation around the right eye, admitting to touching and rubbing it before and after the appearance of symptoms. Overall, he denies any scaling, lumps, or blisters.
Mouth, throat, nose, ears: The patient denies having a sore throat, oral or dental problems, nasal congestion, or hearing loss.
Eyes: The patient admits to having myopia, which he did not attempt to fix with any surgeries or medications. According to the patient, the left eye is not dry or irritated. The right eye is red and itchy. The patient also reports to having blurred vision in his right eye due to excessive tear production and discharge. The difficulty focusing is explained by myopia, the quality of sight is not significantly different.
Genitourinary: The patient denies any changes in urgency. There is no pain during urination.
Gastrointestinal: The patient denies having nausea or loss of appetite. He denies having any abdominal pains.
Musculoskeletal: The patient denies joint pain, muscle pain, cramping, stiffness, or swelling.
Hematologic: The patient denies anemia or unusual bleeding.
Neurologic: The patient denies headaches, tiredness, dizziness, memory loss, weakness, seizures, or numbness.
Allergic: The patient denies having seasonal allergies, food allergies, or animal allergies. There is no family history of allergies as well.
Psychiatric: The patient denies depression, suicidal thoughts, insomnia, or anxiety. He denies having continuous nervousness or stress.
Objective Data
Vital Signs/Height/Weight
- Height: 5’8”
- Weight: 150 lb
- Temperature: 98.5 F
- Pulse: 74 BPM
- BP: 117/73
General Appearance
The patient is a healthy-looking male with no apparent health issues. He does not seem to be in distress. The patient is clear and concise in his speech. He understands all questions and answers them without any problems.
Cardiovascular: Heartbeat is normal with regular rate and rhythm. No gallops, murmurs, clicks, or rubs present. There is no edema, cyanosis, or clubbing.
Respiratory: The patient’s lungs are clear, there are no sounds. The breathing is even and has no obstructions.
Abdominal: Abdomen is non-tender and soft. Bowel sounds are present. There is no guarding and no masses.
Skin: The patient’s skin is dry and warm. There are no ulcers, injuries, or bruises visible. The skin of the right eyelid is slightly pink and inflamed. There is no major inflammation of the eyelid.
Mouth/Throat: Membranes are not dry. The pharynx is normal. The oropharynx is clear.
Eyes: The conjunctiva of the right eye is red. Liquid watery discharge is present in the inflamed eye. Pupils are equal and reactive to light. The patient does not seem to have any further deterioration in eyesight. Red reflex is present bilaterally. There is no strabismus or nystagmus present. The fundoscopic exam is normal.
Assessment
Differential Diagnosis
Subconjunctival Hemorrhage
According to Mayo Clinic (2017), the subconjunctival hemorrhage is a breaking of a blood vessel in the conjunctiva of an eye. This issue presents itself as a red conjunctiva. This type of hemorrhage can occur because of various reasons such as a strong sneeze of a cough. However, this problem does don cause any significant harm to the person’s eye. It usually goes away in a number of days. The patient’s eye does look red. However, other symptoms that the patient experiences are not typically connected to this issue. Subconjunctival hemorrhage is not accompanied by itchiness or irritation. Furthermore, the redness of the eye in the case of this patient is different from redness experienced by people with hemorrhage. Therefore, this diagnosis can be ruled out.
Blepharitis
Blepharitis is the inflammation of the eyelid. The symptoms of this disease include redness and irritation of the eyelid, redness of the eye, swollen eyes, and excessive tearing (National Eye Institute, 2017). Moreover, blepharitis is often followed by crusting of the eyelashes, blurred vision, and frothy tears. Blepharitis is usually caused by bacteria or skin diseases such as acne and scalp dandruff. Many of the symptoms of this disease align with problems of the patient. However, while his eye is red and irritated, his eyelid is not significantly inflamed. Moreover, the crustiness of the eyelashes is mostly likely caused by excessive tearing, which is not frothy. Blepharitis can be ruled out because of the eyelid’s condition.
Conjunctivitis
Conjunctivitis, otherwise called pink eye, is considered to be the most common eye infection (Centers for Disease Control and Prevention, 2017). It can occur due to a number of reasons, including allergic reactions, bacteria, respiratory infections, and bad hygiene. All types of conjunctivitis are characterized by redness and itchiness of the eye, excessive tear production, and discharge. However, some symptoms are different. Allergic conjunctivitis occurs seasonally and is often followed by other types of allergic reactions such as hay fever and asthma. Viral conjunctivitis usually accompanies a common cold. Finally, bacterial conjunctivitis often occurs together with other infections. Furthermore, improper hand washing can cause conjunctivitis as well. Contact lenses may also irritate the eye if they are not stored or handled properly.
Medical Diagnosis
The discharge in the patient’s eye is not thick or frothy, which rules out bacterial conjunctivitis. The patient denies having any infections or allergic reactions. However, he admits to wearing contact lenses, which he acquired rather recently. Therefore, it is safe to believe that the irritation of the right eye is caused by improper lens care. It is possible that the patient failed to clean the contact lenses correctly, which resulted in the inflammation of the right eye. Thus, the diagnosis of conjunctivitis can be confirmed.
Plan
Orders
Most types of conjunctivitis do not require additional treatment (Azari & Barney, 2013). However, to soothe the irritation, the patient should continue to use Visine eye drops and adhere to a stricter handwashing routine. Moreover, the patient should change contact lenses and consider purchasing a different brand of lens solution.
Follow-Up Plans
The next appointment is necessary if the patient continues to experience irritation in his right eye. In this case, the next meeting should include additional tests and follow- up instructions. If the problem does not go away, the patient can take antibiotics to stop the inflammation.
References
Azari, A. A., & Barney, N. P. (2013). Conjunctivitis: A systematic review of diagnosis and treatment. Jama, 310(16), 1721-1730.
Centers for Disease Control and Prevention. (2017). Conjunctivitis.
Mayo Clinic. (2017). Subconjunctival hemorrhage.
National Eye Institute. (2017). Facts about blepharitis.