14 Jan Denies ST and redness Neck
DQ1
A 19-year-old male freshman college student presents to the student health center today with complaints of bilateral eye discomfort. Upon further questioning you discover the following subjective information regarding the chief complaint.
History of Present Illness
Onset
2-3 days ago
Location
Both eyes
Duration
Constant
Characteristics
Both eyes feel “gritty” with mild to moderate amount of discomfort. Further describes the gritty sensation “like sand caught in your eye”
Aggravating factors
None identified
Relieving factors
None identified
Treatments
Tried OTC visine drops yesterday which temporarily improved the redness but the gritty sensation, tearing and itching remained.
Severity
Level of discomfort is 2/10 on pain scale
Review of Systems (ROS)
Constitutional
Denies fever, chills, or recent illnesses
Eyes
Denies contact lenses or glasses, has never experienced these symptoms previously. Last eye exam was “a few years ago”. Denies recent trauma or eye injury. Denies crusting of lids or mucoid or purulent drainage. Bilateral symptoms of +redness, +itching, +tearing + FB sensation.
Ears
-otalgia, -otorrhea
Nose
+occasional runny nose with intermittent nasal congestion, denies sneezing. History of seasonal nasal allergies which is aggravated in the spring but is well controlled on loratadine and fluticasone nasal spray taken during peak season.
Throat
Denies ST and redness
Neck
Denies lymph node tenderness or swelling
Chest
Denies cough, SOB and wheezing
Heart
Denies chest pain
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