| David Stevenson, a 17 YO patient of yours comes in complaining of eye irritation/pain and the feeling that there's something under his right eye lid which is worse when he blinks or moves his eye. He says that it began yesterday afternoon. He also notes that his eye has been red since this morning. |
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Question 1: What other questions might you want to ask?
Answer to Question 1
Even though it seems obvious that the diagnosis would be corneal abrasion and/or foreign
body, it is too soon to reach that conclusion. You still keep the differential in the back
of your head as you progress through the H&P:
Acute Angle Closure Glaucoma
Conjunctivitis
Foreign Body
Iritis
Keratitis
Lacrimal Problems
Scleritis
Question 2: Once again, if you could only ask whether or not
he had two symptoms, which two would be the most important to know?
Answer to Question 2
You ask the two key questions about the presence of pain or decreased function. David
replies that there is significant irritation, but not boring pain. He also doesn't note
any decreased function, but it's hard to tell since he has some difficulty opening his eye
lid without blinking. He also denies any itchiness.
Question 3: Once again, if you could only check whether or
not he had two signs on physical exam, which two would be the most important to
know to rule out major pathology?
Answer to Question 3
With a penlight, you also check his pupillary responses and resting state which are
normal. You also look for ciliary flush which you don't appreciate.
Question 4: Equipped only with this data, what are the
pro's/con's of a diagnosis for each element of your differential for Red Eye?
Answer to Question 4
You go further on your physical exam. You observe no discharge, but note that his eye is
fairly injected, though lacking ciliary flush. Anterior Chamber Depth appears normal
(deep).
Question 5: How does this help you?
Answer to Question 5
With eye pathology, you always want to confirm the patient's perception of any lack of
function/blurry vision. Your nursing staff tried to determine his acuity earlier, but he
was unable to cooperate, blinking and tearing repeatedly.
Question 6: What can you try to help him cooperate?
Answer to Question 6
His acuity is 20/20 in his left eye and seems to be 20/20 or 20/25 in the right.
| Finally, you apply fluorescein dye along with a topical anesthetic (if not done
previously). You observe the following while using a cobalt blue penlight, Wood's lamp, or
slit lamp: The pattern is both linear and vertical. This is suspicious for a foreign body hidden up under the lid. |
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| Inspection of the lid reveals the following: The arrow indicates a small foreign body on an inverted eyelid |
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Your diagnosis is now solid. Next comes treatment.
Question 7: What do you suggest?
Answer to Question 7
Question 8: Many physicians patch eyes also. What does the
literature say about this?
Answer to Question 8
Question 9: When do suggest that he follow up?
Answer to Question 9
Question 10: Lastly, what key question must you remember to
ask?
Answer to Question 10
End of Case 5
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