Chief Complaint Crusty Explained for Students (Easy Guide)
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Original Question
Chief Complaint: “Crusty, irritated left eye.” History of Present Illness A mother brings her 5-year-old son to his PCP with a complaint of a 3-day history of a “crusty and irritated” OS. This morning, the mother noticed increased erythema and crusty white drainage to the lashes and inner canthus. No medications or other treatments were given. The mother is wondering if it is pinkeye because the daycare center the child attends notified parents yesterday that a child had been diagnosed with it. The mother is requesting medication for the child to start treatment, along with asking if it is contagious and if she needs to take off from work to care for the child. She is concerned because she lacks the financial means to take time off work. Review of Systems The ROS is positive for OS erythema and pruritus with white crusty drainage. The ROS is negative for pain, changes in visual acuity, photosensitivity, or recent trauma. The mother denies that the child has had a fever or a change in appetite and energy. There are no ear pain, nasal congestion, sore throat, headache, cough, SOB, rash, or muscle aches. The mother denies a recent viral URI or ear infection and reports no environmental or food allergies nor history of allergic rhinitis. Relevant History There is no significant medical history of concern. The child is generally healthy and was born normally. The patient takes no routine medications. There have been no surgeries or hospitalizations. The family history is unremarkable. It is a nonsmoking home. The child lives with his mother and older brother. He attends kindergarten and an after-school daycare program. Allergies No known drug allergies; no known food allergies. Medications None. Physical Examination â– Vitals: T 37°C (98.6°F), P 92, R 20, BP 106/54, WT 9.07 kg (46 lb), HT 104.14 cm (41 in.), BMI 20.2. â– General: The patient appears to be in no apparent distress, except for rubbing his eyes. He is acting appropriately for his age, is clean and dressed well, and has a caring mother at his side. â– Psychiatric: Cooperative. â– Skin, Hair, and Nails: No abnormal findings. â– Head: Normocephalic. â– Eyes: Left conjunctiva erythema with lid swelling and a small amount of yellow purulent drainage to the lashes. Right conjunctiva is normal. There is no visual acuity deficit. No foreign body. PERRL. Red reflex intact bilaterally. â– Snellen Test: OD 20/20, OS 20/20, OU 20/20. â– ENT/Mouth: TMs present bilaterally with no ear drainage or tenderness to palpation. There is no preauricular lymphadenopathy. BL nares are without erythema, edema, or drainage. Oral mucosa is moist and normal. Normal dentation. The pharynx is normal. â– Neck: No cervical lymphadenopathy. FROM. â– Lungs: CTA bilaterally. â– Heart: RRR. No murmur. â– Abdomen: BS present. Abdomen soft with no tenderness to palpation. â– Musculoskeletal: Moves all extremities well with good strength. â– Neurologic: A&O × 3. Clinical Discussion Questions What are your top three differential diagnoses? What is the most likely diagnosis? Why? What are the most common causes of your diagnosis? Describe the treatment options and diagnostic criteria. Provide references. Describe patient and parent education regarding the diagnosis.
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