The role of a clinician who is building a health history

• • Vision Changes: Has she noticed any blurry vision, double vision, or any difficulty seeing?
  • Photophobia: Is her eye sensitive to light? Does she squint or complain of discomfort in bright light?
  • Associated Symptoms: Has she had any fever, cough, sore throat, runny nose, ear pain, or swollen lymph nodes (especially around the ears or neck)?
  • Trauma or Injury: Has she had any recent injury to her eye, even a minor one? Has anything splashed into her eye?
  • Contact Lens Use: Does she wear contact lenses? If so, what type, how often does she wear them, and what is her cleaning routine? (The note says "unable to open eyes in the morning," suggesting she might not wear contacts, but it's worth confirming).
  • Exposure History: Has she been around anyone else with similar eye symptoms (e.g., at school, home)? Has she been swimming in a pool, lake, or other body of water recently?
  • Allergies (Further Exploration): While the mother denies known allergies, I would ask specifically about seasonal allergies (hay fever), pet allergies, or any new soaps, lotions, or medications she might have come into contact with.
  • Past Ocular History: Has she had any previous eye infections, injuries, or other eye conditions?
  • Medications: Is she currently taking any medications (prescription, over-the-counter, or herbal supplements)?
  • Social History: Does she attend school or daycare? Are there any environmental factors at home or school that might be contributing?

2. Other Objective Findings to Look For:

During the physical examination, I would pay close attention to the following:

• Visual Acuity: Assess her vision in both eyes separately, using a Snellen chart or age-appropriate vision screening tool.
• Pupillary Examination: Check pupil size, shape, reactivity to light (direct and consensual).
• Extraocular Movements (EOMs): Assess her ability to move her eyes in all directions smoothly and without pain.
• External Eye Examination:
  • Eyelids: Note the degree of edema (swelling), redness, warmth, and any tenderness. Look for any vesicles or lesions on the eyelids.
  • Conjunctiva: Examine both the palpebral conjunctiva (lining of the eyelids) and the bulbar conjunctiva (covering the sclera) for the degree and pattern of redness (diffuse or localized), the presence of follicles or papillae (small bumps), and any chemosis (swelling of the conjunctiva).
  • Cornea: Assess the clarity of the cornea. Look for any abrasions, ulcers, or opacities. Fluorescein staining with a Wood's lamp would be helpful to check for corneal abrasions or herpetic lesions.
  • Sclera: Note the color of the sclera (beyond the redness).
• Preauricular Lymph Nodes: Palpate the lymph nodes in front of the ears for tenderness or enlargement, which can be associated with viral conjunctivitis.
• Systemic Examination: Briefly assess for any other relevant systemic findings, such as a rash, especially on the face or around the eyes, or signs of upper respiratory infection.

3. Diagnostic Exams to Order:

Based on the initial presentation, I would consider the following diagnostic exams:

• Fluorescein Stain Examination: To evaluate for corneal abrasions, ulcers (including herpetic keratitis), or foreign bodies.
• Conjunctival Swab for Bacterial Culture and Sensitivity: To identify any bacterial pathogens causing the conjunctivitis and determine appropriate antibiotic treatment. This is particularly important given the purulent, crusty exudates and the severity of the symptoms.
• Viral Culture or PCR of Conjunctival Swab: To rule out viral conjunctivitis, especially if there are preauricular lymph nodes, a lack of significant purulent discharge (though this patient does have crusting), or if bacterial cultures are negative but symptoms persist. PCR can be more sensitive and provide quicker results for certain viruses like adenovirus or herpes simplex virus.
• Allergy Testing (Consideration): If the symptoms were more suggestive of allergic conjunctivitis (e.g., significant itching, watery discharge, history of allergies), allergy testing might be considered later, but it's less likely the primary cause based on the current presentation.

4. Three Differential Diagnoses:

Based on the presenting symptoms of a red left eye, edematous eyelids, and "sand in my left eye," along with the red sclera and dried, crusty exudates (worse in the left eye), my top three differential diagnoses are:

1. Bacterial Conjunctivitis:
2. Viral Conjunctivitis (likely Adenoviral):
3. Allergic Conjunctivitis with Secondary Bacterial Infection:

5. Rationales for Each Differential Diagnosis:

• Bacterial Conjunctivitis:

  • Rationale: The prominent red sclera and the description of dried, crusty exudates, particularly the inability to open the eyes in the morning due to crusting, strongly suggest a bacterial infection. Bacterial conjunctivitis is characterized by a purulent discharge that can cause the eyelids to stick together. The unilateral presentation (left eye worse than right) is also common in bacterial infections, although it can spread to the other eye. The "sand in my eye" feeling can be due to inflammation and the presence of discharge. While allergies were initially denied, a secondary bacterial infection can occur in the context of underlying allergic inflammation.

• Viral Conjunctivitis (likely Adenoviral):

  • Rationale: Viral conjunctivitis, especially caused by adenovirus, is highly contagious and can present with redness, watery discharge (which can sometimes become more mucoid or even have some crusting), a foreign body sensation ("sand in my eye"), and often involves preauricular lymphadenopathy (which needs to be assessed). While the exudate is described as "crusty," it could be dried serous or mucopurulent discharge seen in viral infections. The progression of symptoms over three days and the involvement of both eyes (though one is worse) are also consistent with viral conjunctivitis, as it often starts in one eye and spreads. The absence of reported allergies initially also makes a primary viral infection more likely.

• Allergic Conjunctivitis with Secondary Bacterial Infection:

  • Rationale: Allergic conjunctivitis typically presents with significant itching, redness, watery discharge, and often bilateral involvement. While the mother denies allergies, the child may have undiagnosed seasonal or environmental allergies. The "sand in my eye" feeling can also be present due to conjunctival inflammation. The current presentation of crusty exudates, especially being worse in one eye, suggests a possible secondary bacterial infection superimposed on an underlying allergic inflammation. The initial itching of allergies can lead to rubbing of the eyes, potentially introducing bacteria.

It's important to note that these are differential diagnoses based on the initial information. Further subjective questioning, a thorough objective examination (including assessment for preauricular lymph nodes and corneal involvement), and the results of the diagnostic tests will help to narrow down the most likely diagnosis and guide appropriate management.

1. Other Subjective Data to Obtain:

To get a more complete picture, I would ask the patient and her mother the following questions:

• Detailed History of Present Illness (HPI) - Focusing on the Eye Complaint:
  • Onset and Progression: Can you describe exactly when the redness started? Was it sudden or gradual? How has it changed day by day?
  • Pain: Describe the "sand in the eye" feeling. Is it constant or intermittent? Is there any sharp pain, burning, or itching? On a scale of 0 to 10, how would you rate the discomfort?
  • Discharge: What does the crusty exudate look like? Is it watery, thick, yellow, green, or white? Has there been any discharge during the day? Has the amount changed?