Problem
A 22 year old college student presents to the office with complaints of redness, light sensitivity and tearing of the left eye for the past 24 hours. She notes she also has had a sore throat and a slight cough. She denies itchy eyes, fevers, chills, nausea, vomiting or diarrhea. She denies any changes in vision, blurry vision or pain in the eye. She She denies any sick contacts or pets. She has not taken anything for her symptoms. She does not wear glasses or contact lenses. Physical Exam Vital Signs are normal HEENT: Normocephalic, pupils are equally round with normal constriction, normal accomodation, extra ocular fields intact. Left eye hasl watery discharge with conjunctival injection, non-tender to palpation. Right eye with no discharge but slight conjunctival injection. Fluorescein testing negative bilaterally. Normal Fundoscopic exam. Mildly enlarged left preauricular lymph node. Vision 20/20 Remainder of exam is normal. PMH:Denies PSH: appendectomy Medications: Loratadine (Claritin) prn, YAZ Family HX: Mother: healthy, Father: Stroke Social HX: Works part time at a nursery and is a college student. Denies alcohol, drugs or tobacco products.
Task
1. Based on the case presentation, what is her most likely diagnosis and what is your rationale for choosing this diagnosis?
2. What are 3 other differential diagnosis that you should consider when seeing this patient and why?
3. What is the appropriate treatment for this patient? If you are going to use medications (prescription or over the counter, please list the medication name, strength and dosing for the patient)
4. What type of patient education would you provide to this patient?