Take on the role of a clinician who is building a health history for the following case:
Chief Complaint: A 11-year-old female patient complains of red left eye and edematous eyelids. Her mother states the child complains of “sand in my left eye.”
Subjective: Patient noticed redness three days ago. Denies having any allergies. Symptoms have gotten worse since she noticed having the problem.
VS: (T) 98.2°F; (RR) 18; (HR) 78; BP 128/82; SpO2 96% room air; weight 110 lb.
General: well-developed, healthy, 11 years old
HEENT: EYES: very red sclera with dried, crusty exudates; unable to open eyes in the morning with the left being worse than the right
1. What other subjective data would you obtain?
2. What other objective findings would you look for?
3. What diagnostic exams do you want to order?
4. Name 3 differential diagnoses based on this patient presenting symptoms?
5. Give rationales for your each differential diagnosis.
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?
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?