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.

Sample solution

Dante Alighieri played a critical role in the literature world through his poem Divine Comedy that was written in the 14th century. The poem contains Inferno, Purgatorio, and Paradiso. The Inferno is a description of the nine circles of torment that are found on the earth. It depicts the realms of the people that have gone against the spiritual values and who, instead, have chosen bestial appetite, violence, or fraud and malice. The nine circles of hell are limbo, lust, gluttony, greed and wrath. Others are heresy, violence, fraud, and treachery. The purpose of this paper is to examine the Dante’s Inferno in the perspective of its portrayal of God’s image and the justification of hell. 

In this epic poem, God is portrayed as a super being guilty of multiple weaknesses including being egotistic, unjust, and hypocritical. Dante, in this poem, depicts God as being more human than divine by challenging God’s omnipotence. Additionally, the manner in which Dante describes Hell is in full contradiction to the morals of God as written in the Bible. When god arranges Hell to flatter Himself, He commits egotism, a sin that is common among human beings (Cheney, 2016). The weakness is depicted in Limbo and on the Gate of Hell where, for instance, God sends those who do not worship Him to Hell. This implies that failure to worship Him is a sin.

God is also depicted as lacking justice in His actions thus removing the godly image. The injustice is portrayed by the manner in which the sodomites and opportunists are treated. The opportunists are subjected to banner chasing in their lives after death followed by being stung by insects and maggots. They are known to having done neither good nor bad during their lifetimes and, therefore, justice could have demanded that they be granted a neutral punishment having lived a neutral life. The sodomites are also punished unfairly by God when Brunetto Lattini is condemned to hell despite being a good leader (Babor, T. F., McGovern, T., & Robaina, K. (2017). While he commited sodomy, God chooses to ignore all the other good deeds that Brunetto did.

Finally, God is also portrayed as being hypocritical in His actions, a sin that further diminishes His godliness and makes Him more human. A case in point is when God condemns the sin of egotism and goes ahead to commit it repeatedly. Proverbs 29:23 states that “arrogance will bring your downfall, but if you are humble, you will be respected.” When Slattery condemns Dante’s human state as being weak, doubtful, and limited, he is proving God’s hypocrisy because He is also human (Verdicchio, 2015). The actions of God in Hell as portrayed by Dante are inconsistent with the Biblical literature. Both Dante and God are prone to making mistakes, something common among human beings thus making God more human.

To wrap it up, Dante portrays God is more human since He commits the same sins that humans commit: egotism, hypocrisy, and injustice. Hell is justified as being a destination for victims of the mistakes committed by God. The Hell is presented as being a totally different place as compared to what is written about it in the Bible. As a result, reading through the text gives an image of God who is prone to the very mistakes common to humans thus ripping Him off His lofty status of divine and, instead, making Him a mere human. Whether or not Dante did it intentionally is subject to debate but one thing is clear in the poem: the misconstrued notion of God is revealed to future generations.

 

References

Babor, T. F., McGovern, T., & Robaina, K. (2017). Dante’s inferno: Seven deadly sins in scientific publishing and how to avoid them. Addiction Science: A Guide for the Perplexed, 267.

Cheney, L. D. G. (2016). Illustrations for Dante’s Inferno: A Comparative Study of Sandro Botticelli, Giovanni Stradano, and Federico Zuccaro. Cultural and Religious Studies4(8), 487.

Verdicchio, M. (2015). Irony and Desire in Dante’s” Inferno” 27. Italica, 285-297.

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?
    • 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.

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