Eye Pain

HISTORY:

‍RightLeft eye pain for ‍ ‍hoursdays

Onset: ‍gradualsuddentraumatic, following ‍

Radiation: ‍none

Severity: ‍mildmoderatesevere, ‍012345678910 / 10

Type: ‍dullaching

Pattern: ‍constantintermittent

Worsening factors: ‍none

Treatments tried: ‍none, ‍effectiveineffective

‍redness

‍swelling

‍tearing

‍discharge

‍itching

‍blurred vision

‍vision loss

‍photophobia

‍foreign body sensation

‍fever



EXAM:

General appearance: ‍well-appearing

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Eyes: -R: ‍normal, -L: ‍normal, ‍

Neck: ‍normallymphadenopathy

Neurologic: cranial nerves ‍normal, strength ‍5/5 throughout, sensation ‍normal, reflexes ‍2+ throughout, cerebellar function ‍normal, gait ‍stable



ASSESSMENT:

‍Conjunctivitis ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Blood work: ‍CBC, ‍CRP

- ‍Analgesics

- ‍Topical Antibiotics

- ‍Topical Steroids

- ‍Artificial Tears

- ‍Topical Antiglaucoma

- ‍Topical Antivirals

- ‍Topical NSAIDs

- ‍Topical Cycloplegics

- ‍Topical Anesthetics

- ‍Topical Anticholinergics

- ‍Topical Mydriatics

- ‍Topical Vasoconstrictors

- Referral to ophthalmologist

- Referral to optometrist

- Follow-up in ‍ ‍daysweeks

- Return if pain worsens, if new symptoms develop such as vision changes or discharge from the eye, or if symptoms do not improve with treatment