EM H&P 1

Chief Complaint:
“Right eye pain and redness” x 6 hours

History of Present Illness:
35-year-old female with no significant past medical history presents to the ED with complaints of right eye pain and redness after being hit in the right eye by her child’s toy earlier today. She reports the incident occurred this afternoon while she was playing with her child. The patient describes lateral redness to the right eye and mild discomfort, rated as 2/10, and is concerned due to the persistent redness. She wears corrective glasses for myopia but has not experienced any vision problems today. She denies any changes in vision, loss of vision, photophobia,foreign body sensation, headache, nausea, vomiting, or discharge from the eye.

Past Medical History:

  • Myopia (Glasses wearer)

Medications:

  • None

Allergies:

  • No known drug, food, or environmental allergies

Social History:

  • Smoking: Never
  • Alcohol: Never
  • Illicit Drug Use: Denies any use
  • Occupation: Housewife
  • Exercise: Walks daily
  • Diet: Balanced diet

Review of Systems :

  • General: Denies fever, chills, weight changes, fatigue, or night sweats
  • HEENT:
    • Eyes: Right eye pain and redness; no visual changes, loss of vision, or photophobia
    • Other HEENT symptoms: Denies sore throat, hearing loss, or nasal congestion
  • Cardiovascular: Denies chest pain, palpitations, or edema
  • Pulmonary: Denies cough, shortness of breath, or wheezing
  • Gastrointestinal: Denies nausea, vomiting, diarrhea, or constipation
  • Musculoskeletal: Denies muscle or joint pain
  • Neurologic: Denies headache, dizziness, or focal weakness

Physical Exam:

  • Vitals: BP: 118/76 mmHg | HR: 72 bpm | RR: 16 | Temp: 98.6°F | SpO2: 98% on room air
  • General: 35-year-old female in no acute distress, alert and cooperative
  • HEENT: PERRLA, EOM intact. Subconjunctival hemorrhage present in the right eye with lateral redness, no discharge. Fluorescein uptake present in the right eye, no foreign bodies detected.
  • Ophthalmologic: Intraocular pressure 15 mmHg in the right eye and 17 mmHg in the left eye. 20/20 vision OD, OS, and OU with corrective glasses.
  • Heart: Regular rate and rhythm, no murmurs, rubs, or gallops
  • Lungs: Clear to auscultation bilaterally.

Labs/Imaging:

  • Fluorescein Staining: Positive for fluorescein uptake in the right eye 7 o clock potion.
  • Intraocular Pressure: 15 mmHg right eye, 17 mmHg left eye. Normal limits.

Differential Diagnosis (DDx):

  • Subconjunctival Hemorrhage/Superficial Corneal Abrasion
  • Anterior Hyphema: Unlikely at this time given the absence of significant pain, blurry vision, or an elevated intraocular pressure . No blood seen in the anterior chamber upon examination.
  • Globe Rupture: Unlikely given the lack of visual changes or significant pain.
  • Orbital Fracture: Unlikely, as there is no history of significant trauma or orbital swelling.

Assessment:
35-year-old female presenting with right eye pain and redness following blunt trauma to the right eye. Patient has a lateral subconjunctival hemorrhage with fluorescein uptake,consistent with a mild corneal abrasion.

ED course:Tetracaine drops

Plan:

#Subconjunctival hemorrhage with mild corneal abrasion

  • Moxifloxacin ophthalmic solution 0.5% 1 drop twice daily
  • Educate patient on proper eye protection and avoiding further trauma to the affected eye.
  • Advised outpatient follow up with eye doctor 
  • Return precautions: Patient instructed to return to the ED if experiencing worsening pain, vision changes, photophobia, or increased redness.

Disposition:

Discharged with advice to follow up with ophthalmology in 24-48 hours if symptoms do not improve.