Summary:
This is a 19yo male college student with a CC of acute onset of constant “gritty” or FB sensation to OU associated with 2/10 pain, erythema, lacrimation, and pruritus 2-3 days ago. There are no aggravating or relieving factors. Pt used OTC visible gtts with temporary relief to erythema only. Denies using any corrective glasses of contact lens. No crusting of lids or mucoid or purulent discharges. Reports occasional rhinorrhea with intermittent nasal congestion without sneezing. Denies fever, chills, or recent illnesses, otalgia, otorrhea, ST, lymphadenopathy, LN tenderness, cough, SOB, and wheezing. PMH significant for seasonal allergic rhinitis in the spring.
Physical exam is significant for normal uncorrected visual acuity 20/20, PERRL, and minimal photosensitivity OU, b/l diffuse conjunctival erythema and lacrimation without any mucoid or purulent discharges or visible FB under the lids. Nasal …show more content…
The patient does not have preauricular lymphadenopathy, any mucoid discharges, or any recent illnesses or upper respiratory infection typically associated with viral causes. This makes viral conjunctivitis an unlikely diagnosis. The patient presents to the clinic in October and both bacterial and allergic conjunctivitis can occur in the fall. The patient complaints of “gritty” or FB sensation, however, he does not have the classic mucopurulent (yellow-green) discharge or crusting of lids which is characteristic of bacterial conjunctivitis. The patient has occasional rhinorrhea, pale and boggy turbinates with mild to moderate edema and clear nasal drainage, and a positive history of seasonal nasal allergies. This is highly indicative of an allergic
This is a 19yo male college student with a CC of acute onset of constant “gritty” or FB sensation to OU associated with 2/10 pain, erythema, lacrimation, and pruritus 2-3 days ago. There are no aggravating or relieving factors. Pt used OTC visible gtts with temporary relief to erythema only. Denies using any corrective glasses of contact lens. No crusting of lids or mucoid or purulent discharges. Reports occasional rhinorrhea with intermittent nasal congestion without sneezing. Denies fever, chills, or recent illnesses, otalgia, otorrhea, ST, lymphadenopathy, LN tenderness, cough, SOB, and wheezing. PMH significant for seasonal allergic rhinitis in the spring.
Physical exam is significant for normal uncorrected visual acuity 20/20, PERRL, and minimal photosensitivity OU, b/l diffuse conjunctival erythema and lacrimation without any mucoid or purulent discharges or visible FB under the lids. Nasal …show more content…
The patient does not have preauricular lymphadenopathy, any mucoid discharges, or any recent illnesses or upper respiratory infection typically associated with viral causes. This makes viral conjunctivitis an unlikely diagnosis. The patient presents to the clinic in October and both bacterial and allergic conjunctivitis can occur in the fall. The patient complaints of “gritty” or FB sensation, however, he does not have the classic mucopurulent (yellow-green) discharge or crusting of lids which is characteristic of bacterial conjunctivitis. The patient has occasional rhinorrhea, pale and boggy turbinates with mild to moderate edema and clear nasal drainage, and a positive history of seasonal nasal allergies. This is highly indicative of an allergic