Answer Happy

ASSESSING THE EYES CASE STUDY Clinical Scenario A female patient, 29 years old, comes to the urgent care center complaining of right eye redness with green drainage in her eye when she woke up this morning. She states that she does not have pain in her right eye. She states that her eyes frequently feel "gritty." She reports that she just moved to a new apartment in an old historical home and may be developing allergies to something in the environment. Interview Select the appropriate questions to ask your patient. "How long have you had the redness in your right eye?" "Do you have any history of cataracts?" "Have you had an injury to your eye?" "Have you tried any eye drops?" "Why did you move to an old historical home when there are newer apartments?" "What treatments have you used?" "What are your allergies?" "Do you wear glasses or contacts?"| "Do you feel like your eyes are dry?"
Focused Review of Systems Reports redness in right eye started 48 hrs ago Woke up with green drainage on both eyelids this morning. Reports last eye examination in June of this year. Reports using artificial tears at times for "gritty eyes." Wears disposable contact lenses for nearsightedness. Reports allergies to dust (sneezing and watery eyes). Denies blurry vision, diplopia, itchy eyes, photophobia, flecks in the field of vision, or flashing lights. Documentation: Review of Systems Fill in the circle next to reported symptoms. o Blurry vision O Diplopia O Flashing lights O Floaters o Itchy O Photophobia O Scotoma Tearing O Dry eyes Discharge: Right eye: 0 Green O Yellow Clear Left eye: O Green O Yellow Clear COMMENT Sclera: Red: 0 Right eye o left eye Sclera: Yellow: 0 Right eye o Left eye Sclera: Blood shot: 0 Right eye left eye COMMENT Visual impairment: 0 Glasses O Contacts O Nearsightedness O Farsightedness Last eye examination: COMMENT:
Assessment Eyes and eyebrows symmetrical. Palpebral fissures equal. Eyelashes evenly distributed. Right cyelashes crusty with green drainage. Right eyelid edema. Left eyelid edema, Cornca/lens: no opacities. Conjunctiva: pink and moist. Right eye: small amount of green drainage. Sclera: left eye, clear, right eye, erythema. PERRLA. Pupil size: 3 mm bilaterally, Bilateral lacrimal ducts: nontender. Red reflex: present bilaterally Documentation: Assessment Fill in your assessment findings EYES O Symmetrical Asymmetrical Palpebral fissures: o Equal o unequal COMMENT EYEBROWS O Symmetrical Asymmetrical Alopecia COMMENT: EYELIDS O Even distribution Crusty: O Right eye o Left eye Edema: 0 Right eye o Left eye Ptosis: O Right eye o Left Eye Ectropion: Right eye o left Eye Entropion: Right eye o Left Eye Palpebral fissures: o Equal o unequal COMMENT: DRAINAGE Right eye: Yellow Green Left eye: Yellow Green COMMENT CONJUNCTIVA O Pink Red Pale O Moist Dry COMMENT PUPIL SIZE Right eye: 0 2 mm 0 3 mm 0 4 mm 5 mm 6 mm 0 7 mm 8mm Left eye: 2 mm 3 mm 4 mm 5 mm 6 mm 97 mm 8 mm COMMENT PUPILS Equal Unequal Round Anisocoria Miosis Mydriasis Reactive to light Nonreactive to light: Bilaterally Right eye Left eye Reactive to accommodation COMMENT SCLERA Right eye: White Yellow Red Left eye: White Yellow Red COMMENT CONJUNCTIVA HEMORRHAGE O Right eye Left eye Couvent
Documentation: Assessment (cont'd) LACRIMAL DUCT INSPECTION O No Swelling Swelling: 0 Bilaterally O Right eye o Left eye Excessive Tearing: 0 Bilaterally O Right eye o Left eye PALPATION Right eye: O Tender o Nontender Left eye: 0 Tender Nontender COMMENT: RED REFLEX PRESENT Bilaterally O Right eye o Left eye COMMENT