Patient information – MaryKate, 7yrs, F, Caucasian and insurance not provided.
S.
CC – Red, itchy and burning eyes.
HPI: MaryKate is a 7yr old female child presented to the clinic with c/o redness, drainage, burning and itching of the eyes for two days. The symptoms first started on her left eye and spreads to the right eye this morning. She also has a recent illness of cold with a runny nose and nasal congestion that last about a week and improving with OTC cold medications. She did not miss any school as she never had any fever. She came to the clinic for further evaluation as her mother also noticed some redness and goop in her eyes.
O: Two days ago
L: Both eyes.
D: Started on the left eye two days ago and spread to the right eye this morning.
C: Redness, Drainage, itching
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A
Differential diagnosis
Viral conjunctivitis (ICD 10: B 30.1)
Inflammation and infection of the conjunctiva is known as conjunctivitis, and is characterized by dilatation of the conjunctival vessels, that cause hyperemia and edema of the conjunctiva and is often associated with discharge. Viruses are the most common cause of acute conjunctivitis. Among them, adenoviruses cause sixty five to ninety percent of viral conjunctivitis. The viruses spread through direct contact through contaminated fingers, swimming pool water, medical instruments or personal items. Lymphadenopathy is present in fifty percent of viral conjunctivitis and is more prevalent in viral conjunctivitis (Azari & Barney, 2013).
Pertinent positives: Physical exam reveals itching, redness, burning and tearing of the eyes. H/o cold for a week. Positive adenovirus rapid screening test.
Pertinent Negatives: None
P.
Diagnostics: None
Rx: No effective antiviral treatment is available. Treatment of viral conjunctivitis is mainly supportive. Therefore, MaryKate can be treated with artificial tears 1-2 drops in each eye as needed and cold compress to relive her