Eye Pain

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Presents with a ‍-‍day history of ‍rightleft eye pain

Onset was ‍gradualsuddentraumatic, started ‍whileafter ‍

Location is ‍diffuse

Radiation ‍none to ‍

Rated at ‍012345678910 / 10 ‍

Described as ‍dullaching

Pattern ‍persistentintermittent

Worsening factors: ‍none

Alleviating factors: ‍none, ‍effectiveineffective



Associated symptoms: *Try using right-click for negatives*

‍redness

‍swelling

‍tearing

‍discharge

‍itching

‍blurred vision

‍vision loss

‍photophobia

‍foreign body sensation

‍fever, up to ‍°, over ‍ ‍hoursdays



Contributing factors:

‍extended screen time

‍exposure to sun or UV light

‍grinding

‍contact lens use

no history of: ‍glaucoma, ‍eye trauma, ‍ocular migraines, ‍previous eye surgeries, ‍autoimmune disease

no use of: ‍medication at risk of closed-angle glaucoma, ‍new medication





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

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

Eyes: conjunctiva/sclera ‍normal, lids/lashes ‍normal, cornea ‍intact, ‍PERRL, extraocular movements ‍intact, OD 20/‍, OS 20/‍

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Neurologic: cranial nerves ‍intact, strength ‍intact 5/5, sensation ‍intact, reflexes ‍intact 2+, cerebellar function ‍intact, gait ‍steady





ASSESSMENT:

‍Conjunctivitis ‍likelysuspectedpossible

DDx: conjunctivitis, corneal abrasion, glaucoma, uveitis, dry eye syndrome, scleritis, keratitis, iritis, foreign body in the eye, contact lens complications, blepharitis, endophthalmitis, orbital cellulitis, herpes zoster ophthalmicus, chemical burn, trauma, migraine with aura, cluster headache, sinusitis, giant cell arteritis, tumor in the orbital region





PLAN:

Investigations:

- Blood work: ‍CBC, ‍CRP

Treatments:

- ‍Analgesics

- ‍Topical Antibiotics

- ‍Topical Steroids

- ‍Artificial Tears

- ‍Topical Antiglaucoma

- ‍Topical Antivirals

- ‍Topical NSAIDs

- ‍Topical Cycloplegics

- ‍Topical Anesthetics

- ‍Topical Anticholinergics

- ‍Topical Mydriatics

- ‍Topical Vasoconstrictors

Further care:

- 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