Ophthalmology/Eye Institute

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 Department of Ophthalmology Case Studies

 

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HPI: 31 y/o male who presents with 4 day hx of sudden-onset burning, irritation, FB sensation, photophobia, excessive tears and mild redness in both eyes. The sxs began OD, then noticed OS 3 days later. He denies green mucous discharge, hx of ocular trauma, decreased vision, diplopia, hx ocular seasonal allergies or contact lens use.

POHx: none

OcMeds: none

PMHx: Myopia.

FamHx: No eye dz. No hx atopy in family.

SocHx: Single. No EtOH/tobacco/drug use. No STD risk.

Medications: Multivitamin

Allergies: NKDA

ROS: No recent URI, no sick contacts, no contacts with children, no recent outdoors exposures, no hx of eczema or seasonal allergies.

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