Date of visit: October 20, 2017
A 19-year-old male freshman college student presents to the student health center
today with complaints of bilateral eye discomfort. Upon further questioning you discover
the following subjective information regarding the chief complaint.
History of Present Illness
Onset 2-3 days ago
Location Both eyes
Duration Constant
Both eyes feel "gritty" with mild to moderate amount of discomfort.
Characteristics
Further describes the gritty sensation "like sand caught in your eye"
Aggravating
None identified
factors
Relieving
None identified
factors
Tried OTC visine drops once yesterday which temporarily improved the
Treatments redness but the gritty sensation, tearing and itching remained.
Severity Level of discomfort is 2/10 on pain scale
Review of Systems (ROS)
Denies fever, chills, or recent illnesses
Constitutional
Denies contact lenses or glasses, has never experienced these
symptoms previously. Last eye exam was "a few years ago". Denies
Eyes eye injury, trauma, visual changes or dryness. Denies crusting of lids or
mucoid or purulent drainage. Bilateral symptoms of +redness, +itching,
+tearing + FB sensation.
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