CHIEF COMPLAINT: Left eye injury.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic male who presents to the emergency department for a left eye injury. The patient states earlier today something went into his left eye. The patient states he then thoroughly irrigated out the eye for 30 minutes and did remove a piece of glass. The patient states that since then, he has had increased pain in his left eye as well as some photophobia. The patient states he then presented for further evaluation of this. The patient denies any contact lenses; however; he states he does occasionally wear glasses for astigmatism. The patient denies any blurry or double vision. The patient also denies any bleeding. The patient does state he has a foreign body sensation in his left eye. The patient states he had tetanus vaccination approximately four years ago. The patient currently has no ophthalmologist; however, he does have a primary physician.
PAST MEDICAL HISTORY:
1. Knee surgery.
2. Vasectomy.
CURRENT MEDICATIONS: Hydrocodone as needed.
ALLERGIES: PENICILLIN.
SOCIAL HISTORY: The patient smokes half pack of cigarettes a day, occasionally drinks alcohol, denies use of illicit or IV drugs.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: As stated above, otherwise negative per the patient.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 136/84, pulse 82, respirations 18, temperature 98.4, and O2 saturation 97% on room air.
GENERAL: This is a well-developed, well-nourished (XX)-year-old male who is alert and oriented x3 and appears to be in no acute distress. The patient is cooperative, communicates well, and was ambulatory here in the emergency department.
HEENT: Normocephalic. Eyes: Equal, round, and reactive to light and accommodation. Extraocular movements are intact bilaterally. Conjunctiva of right eye is pink without discharge and sclera is anicteric. Conjunctivae of left eye is slightly injected. Sclera is anicteric. The patient does have some clear drainage from his left eye. TMs appear clear. Buccal mucosa is pink and moist. Pharynx is without erythema or exudate.
NECK: Supple without lymphadenopathy. Trachea is midline.
LUNGS: Clear to auscultation bilaterally. No wheezes, rales or rhonchi noted.
HEART: Regular rate and rhythm. No murmurs, rubs, gallops noted.
EXTREMITIES: The patient moves all extremities without difficulty.
NEUROLOGIC: Cranial nerves II-XII are intact. DTRs are 2+ bilaterally of both upper and lower extremities. Muscle strength 5/5 of all extremities. No focal deficits.
SKIN: Warm and dry to touch.
EMERGENCY DEPARTMENT COURSE: The patient was examined. At that time, the patient’s visual acuity was right eye 20/40, left eye 20/40, both eyes 20/25.
PROCEDURE NOTE: The patient’s left eye was anesthetized with tetracaine eye drops and fluorescein stain was then applied. Upon visualization with the Wood’s lamp, the patient did have uptake for a positive corneal abrasion. Upon further examination, there are no foreign bodies within the patient’s left eye. Upon examination with the slit-lamp, the patient’s eye showed positive corneal abrasion. There is no disruption into the chamber. There is no retinal flaring or hemorrhage.
IMPRESSION: This is a (XX)-year-old gentleman who presents to the emergency department for left eye injury. Upon examination, the patient had no foreign body within the left eye. The patient had a normal slit-lamp exam. The patient did have positive uptake for a corneal abrasion to the left eye with examination under the Wood’s lamp. At this time, we do feel the patient is stable for discharge home. He will be discharged with eye drops as well as a few Vicodin for pain. The patient was encouraged to follow up with his primary physician for persistent symptoms.
DIAGNOSIS: Corneal abrasion to left eye.
PLAN:
1. Ciloxan ophthalmic drops.
2. Vicodin 5/500, #12. We did warn the patient no drinking alcohol while taking.
3. Follow up with Ophthalmology.
4. Return for any worsening symptoms.
DISPOSITION: The patient was discharged to home in stable condition.
