2-4 PATIENT NOTE: EYE PAIN HISTORY: Describe the history you just obtained from this patient.

Include only information (pertinent positives and negatives) relevant to this patients problem(s). HPI: 28 YO MALE C/O RIGHT EYE PAIN. PATIENT REPORTS THE PAIN STARTED 1 WEEK AGO AFTER PUTTING PAINTED LOGO ON HIS RIGHT CHEEK. REPORTS ITCHING, GETTING WORSE, CLOUDY RIGHT EYE VISION, THICK YELLOW DISCHARGE IN THE MORNING. RIGHT EYE WAS RED SWOLLEN UP TO YESTERDAY AND SLIGHT DRYNESS. REPORTS DIFFICULTY DRIVING NO NIGHT VISION DISTURBANCE. NO BOWEL OR BLADDER CHANGES, NO DIZZINESS OR HEADACHE. NO RECENT INFECTIONS, RASH OF CHEST PAIN. NO LEFT EYE SYMPTOMS. ROS: NEGATIVE EXCEPT AS NOTED ABOVE ALLERGIES: LOTIONS AND DETERGENTS MEDICATIONS: ALBUTEROL INHALER PRN PMH: DIAGNOSED WITH ASTHMA AS A CHILD PSH: NONE SH: DENIES TOBACCO, ETOH, OR DRUG USE. 10 PLUS SEXUAL PARTNER IN THE LAST YEAR, DOES NOT USE CONDOMS. WORKS AS A MEDICAL ASSISTANT LIVES ALONE. PHYSICAL EXAM: Describe any positive and negative findings relevant to this patients problem(s). Be careful to include only those parts of examination you performed in this encounter. HE IS NO ACUTE DISTRESS. HIS VITALS ARE WNL. HIS HEAD, EYES, NOSE, AND THROAT APPEAR NORMAL. HIS PUPILS ARE REACTING TO DIRECT AND CONSENSUAL LIGHT, EXTRA OCULAR MUSLCES ARE INTACT AND THE RIGHT FIELDS GAZE IS WNL. THERE WERE NO FUNDOSCOPIC ABNORMALITIES AND EYES CONVERGE NOMAL BILATERALLY. HIS VISUAL ACUITY IS 20/40 BILATERALLY. HIS NEUROLOGICAL EXAM WAS NORMAL WITH CN 2-12 INTACT AND STRENGTH WAS 5/5 THROUGHOUT. HIS SENSATION TO DULL AND SHARP WAS INTACT AND REFLEXES WERE NORMAL (2+) THROUGHOUT. THERE WAS NO BRUISING OR CYANOSIS ON THE EXTREMITIES. DATA INTERPRETATION: Based on what you have learned from the history and physical examination, list up to 3 diagnoses that might explain this patients complaint(s). List your diagnoses from most to least likely. For some cases. Fewer than 3 diagnoses will be appropriate. Then, enter the positive or negative findings from the history and physical examination (if present) that support each diagnosis. Lastly, list initial diagnostic studies (if any) you would order for each listed diagnosis (e.g. restricted physical exam maneuvers, laboratory tests, imaging, ECG, etc. Diagnosis #1: CORNEAL ABRASION HISTORY FINDING(S) - Pain started after using face paint on right cheek 1 week ago

PHYSICAL EXAM FINDING(S) - Right eye is red and swollen

-C/o itching, thick yellow discharge and cloudy right eye vision -Pain is getting worse Diagnosis #2: CONJUNCTIVITIS HISTORY FINDING(S) - C/o right eye pain and itching - Cloudy right eye vision, and thick yellow eye discharge -Pain is getting worse Diagnosis #3: ANTERIOR UVEITIS HISTORY FINDING(S) - Thick yellow discharge in the right eye - Cloudy right eye vision - C/o right eye pain and itching

-Eye convergence normal B/L -No fundoscopic abnormalities

PHYSICAL EXAM FINDING(S) - Right eye is red and swollen - Eye convergence normal B/L - No fundoscopic abnormalities

PHYSICAL EXAM FINDING(S) - Right eye is red and swollen - Eye convergence normal B/L - No fundoscopic abnormalities

Diagnostic Studies: - ELISA/RAST FOR IGE ANTIBODIES - ALLERGY SKIN TEST - SLIT LAMP EXAMINATION - CBC WITH DIFFERENTIALS - URINALYSIS - EYE DISCHARGE CULTURE FOR BACTERIAL OR VIRAL INFECTION