CHIEF COMPLAINT: Eye pain.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female with a past medical history significant for asthma and hypertension who states, over the past two weeks, she has been having fever-type symptoms, including itchy eyes with copious watery discharge. She has been using Benadryl and over-the-counter eye drops with some relief. She states that approximately two days ago, the itching/burning sensation switched to a painful stabbing, burning sensation in her left eye. She states that she has been unable to open her eyes since that time, and upon awakening this morning, the eye pain was so severe she decided to come to the emergency department. She states that she is having some blurry vision with halos around lights. She denies any headaches, nausea, vomiting or other systemic complaints.
PAST MEDICAL HISTORY:
1. Asthma.
2. Hypertension.
MEDICATIONS:
1. Blood pressure medications.
2. Hypercholesterolemia medication.
3. Asthma medication, all of which she cannot recall.
ALLERGIES: ASPIRIN AND CODEINE.
SOCIAL HISTORY: The patient denies any tobacco use, alcohol consumption or IV or recreational drug use.
REVIEW OF SYSTEMS: As per HPI. All other systems reviewed negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 97.8, pulse 86, blood pressure 136/92, respiratory rate 18, and oxygen saturation 95% on room air.
GENERAL: The patient is a well-appearing female, in no acute distress.
HEENT: Pupils are equal, round, and reactive to light. The patient’s conjunctivae were mildly injected bilaterally with limbic sparing. She had no evidence of increased intraocular pressure in either globe to manual palpation. Tetracaine was applied and she had immediate resolution of her symptoms in her left eye. Fluorescein staining revealed a small area of uptake in the left cornea, just 6 o’clock of the mid pupil. Pupillary reflex was again tested after fluorescein staining and showed both pupils to be equal, round, and reactive from 4-2 mm with no pain on pupillary reaction. Her bulbar conjunctivae were free of any foreign objects or lesions bilaterally. Extraocular movements were intact without pain. Oropharynx was moist without erythema or exudate. Visual acuities were 70/20 separately in each eye and 40/20 in both eyes when uncovered. She did have near vision to 18 point font at approximately 10 inches in the left eye.
NECK: Supple without lymphadenopathy.
EMERGENCY DEPARTMENT COURSE: The patient was seen and evaluated. She had fluorescein staining performed, which revealed an area of ulceration. She was taken to the eye room, and a slit-lamp examination was performed which again revealed a clear abrasion on the left cornea with no evidence of ulceration, no anterior chamber flare, cells or white cells. Her case was discussed with Ophthalmology who agreed with erythromycin topical ointment and to have the patient follow up in their clinic later this afternoon. The patient was advised of this and given scripts for erythromycin ointment as well as Vicodin for pain and given one Vicodin here in the emergency department after which she was discharged ambulatory in good condition.
IMPRESSION: Corneal abrasion.
PLAN:
1. The patient is to follow up with Ophthalmology.
2. The patient was given scripts for erythromycin ointment to be used q.i.d. in both eyes as well as Vicodin one p.o q. 4 hours p.r.n. pain, #20, no refills.
3. The patient was told to return for acute worsening of her pain, acute loss of her vision or other worrisome symptoms.
DISPOSITION: The patient was discharged to home in stable condition.
