eye complaint

onset

hours days weeks months years
sudden gradual

new?

new issue previously known issue

side

left right bilateral L>R R>L

symptoms

redness pain eyelid swelling dryness

discharge

none watery discharge purulent discharge crusting

pain

none mild mild-moderate moderate moderate-severe severe

pruritus

none mild moderate severe

status

improving unchanged resolved gradually worsening significant worsening

trauma

yes no

FB sensation

yes no

HPI

---

negatives/ROS

inspection

R conjunctivitis L conjunctivitis
R normal L normal
+ swelling  –

discharge

none watery discharge purulent discharge crusting

CN exam

normal normal pupils

snellen

not tested
L 20/20 20/25 20/30 20/40 20/50 20/70 20/100 20/200
R 20/20 20/25 20/30 20/40 20/50 20/70 20/100 20/200

other

Assessment:

bacterial conjunctivitis allergic viral subconjunctival hemorrhage dry eyes corneal ulcer
anterior uveitis angle closure glaucoma scleritis

details

---

Plan:

self-limited

Rx

antibiotics topical antihistamine PRN artificial tears

follow-up

2-4 weeks PRN only

RTC

instructions given

other