iHuman Case Study: RF, 6-year-old, Caucasian, Female CC (chief complaint): Red eye

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iHuman Case Study: RF, 6-year-old, Caucasian, Female CC (chief complaint): Red eye Primary Care of Adolescents & Children Patient Information: RF, 6-year-old, Caucasian, Female Subjecti... ve: CC (chief complaint): Red eye HPI: Ramona is a 6-year-old female who presents today with her mother with complaints of redness to her right eye. The redness began 3 days ago and is associated with purulent discharge that becomes worse overnight. She has red conjunctiva with purulent exudate of the right eye without pain, tenderness, or swelling. Left eye normal appearing. She has had nasal congestion for 3 days. The mother reports that 2 other children from school have similar symptoms. Ramona was sent home from school today with instructions that she was to be evaluated before returning to school. Physical exam with findings of right eye conjunctival injection and purulent discharge. There is no decreased vision or ulcerations. Nasal passages normal appearing. No significant past medical history. Current meds: None Allergies: NKDA Pertinent PMHx: Ramona is in general good health. No pertinent past medical history noted. She is up to date on immunizations and has regular check-ups. Immunizations: Hep B - series completed at 18 months RV1 - series completed at 4 months DTaP - series completed at 5 years Hib - series completed at 15 months PCV13 - series completed at 15 months IPV - series completed at 5 years IIV – Annual vaccination completed at 5 years MMR - series completed at 5 years VAR - series completed at 5 years Hep A - series completed at 18 months Social hx: Lives at home with mother and father in an apartment. No siblings. Mother is an engineer. Father works in finance. Fam Hx: 1. Mother, 38-years-old, healthy 2. Father, 40-years-old, healthy History Questions Asked: 1. How can I help you today? 2. What symptom is most distressing for you? 3. What happened? 4. How can I help her today? 5. Does she have any other symptoms or concerns we should discuss? 6. Does she have pain anywhere? If so, where? 7. Do you have pain anywhere? If so, where? 8. Has anyone else she knows developed these symptoms? 9. When did her eye problems start? 10. How quickly did her eye problem come on? [Show More]

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