Patient particulars.

Name: Awang Sofrie Bin Daud. ID No: 871011-12-5053. Sex: Male.

Nationality: Malaysian. Date of birth: 11/10/1987. Age: 25 years old.

Race: Bisaya. Religion: Muslim. Marital status: Single.

Chief Complaint.

o Right eye redness since 2 days ago.

History of Present Illness.

o Right eye.
o Swelling on and off for 2 days.
o Eye discomfort.
o Itching.
o Pain (moderate).
o No bleeding noted.
o No blurring of vision.
o No fever.

History of past surgical and Medical illness.

No know past surgical and medical illness.

No know past history of drug and food allergies.

Social history.

None taken.

Family medical history.

None taken.

Physical Examination at Eye clinic.

 1. General examination.
Patient alert and conscious.
Dehydration fair.
No central cyanosis.
Glasgow coma scale 15/15.
2. Vital sign.
Blood pressure 130/80 mmHg.
Pulse rate 79 bpm
Respiration rate 25/minute
Temperature 36.8oc
3. Eye examination.
Right eye.
Red eye.
Injected conjunctiva.
Tearing (watery eyes).
No blurring of vision.
Visual acuity normal (6/6).
No bleeding noted.
No abnormal discharge noted.
Left eye.
No blurring of vision.
Visual acuity normal (6/6).
Conjunctiva normal.
No associated problem or complaint by patient.
4. Chest (Heart).
Dual rhythm and no murmur.
5. Chest (Lung).
Good air entery.
No rhonci and crepitation.
6. Abdominal.
Soft during palpitation.
Normal bowel sound.
7. Upper and lower limbs.
No peripheral cyanosis.
Able to move all limbs.
No edema noted.
8. Central nervous system.
No neurogical defect detected.

Summary of finding:

Lung: Good Air entery,

No Rhonci, no Crepitation
CVS:
DRNM
Right eye: pupil Left eye: pupil
(0.3mm), cornea (0.3mm), cornea
and lens clear, and lens clear,
upper and lower upper and lower
eye lid slightly eye lid normal
swell
 Watery eye

Conjunctiva
Conjunctiva normal.
mild injected

Soft, normal
bowel sound IOP=15 IOP=17
V.A= 6/6 V.A= 6/6

Fundi: clear
Fundi: clear

Diagnosis:

o Allergic conjunctivitis.

Differential Diagnosis.

o Viral conjunctivitis.
o Bacterial conjunctivitis.
o Blepharitis.

Investigation.

Ophthalmoscope and microscope.

 o Taken for basic eye examination and detection of:
Foreign body.
Bleeding.
Other associated problem.
o Ophthalmoscope result finding (right eye).
Blood vessels of the conjunctiva dilated.
Watery eye.
Upper and lower lid swell (mild).
No foreign body and bleeding noted.
Lens normal.
Visual acuity. (Refer result at summary finding).
o It is a test for testing acuteness or clearness of vision, which is dependent on the
sharpness of the retinal focus within the eye and the sensitivity of the
interpretative faculty of the brain.
o Using Snellen chart.
Intraocular pressure (IOP) measurement (Refer result at summary finding).
o Measurement done using non-contact tonometer.
o Its a routine investigation for each patient that came to eye clinic.
Funduscopy. (None taken).
o Taken if complication of the fundus occur.
Full Blood Count. (None taken).
o Taken for detection of infection and other complication.

Management.

Referral case from Emergency Department of HQE1 to Ophthalmology clinic (Eye clinic) prior to
chief complaint. Upon arrival, patient being send to examination room (Room 1) for basic eye
examination.

Result finding.
o Ophthalmoscope result finding (right eye).
Blood vessels of the conjunctiva dilated.
Watery eye.
Upper and lower lid swell (mild).
No foreign body and bleeding noted.
Lens normal.
o Intraocular pressure.
Right eye: 15. Left eye: 17
o Visual acuity.
Right eye: 6/6. Left eye: 6/6.
Vital sign upon arrival.
o Blood pressure 130/80 mmHg.
o Pulse rate 79 Bpm.
 o Respiration rate 25/minute.
o Temperature 36.8oc
Management.
o The main step for treatment of allergic conjunctivitis is by avoiding exposure to the
cause or allergen.
o For reducing swelling and discomfort, cool wet compress can be done at home.
o Example of Ophthalmic Medication for allergic conjunctivitis.
Artificial tear eye drops (for mild allergic conjunctivitis).
Antihistamine eye drops.
- Emedastine (Emadine).
- Azelastine (Optivar).
Mast cell stabilizer, anti-inflammatory eye drops.
- Lodoxamide (Alomide).
- Olopatadine (Patanol, Pataday).
- Cromolyn (Opticrom).
Nonsteroidal anti-inflammatory drugs.
- Flurbiprofen (Ocufen).
- Ketorolac (Acular).
Corticosteroid eye drops (for severe reactions)
- Loteprednol etabonate (Lotemax, Alrex)
Medication that being given to this patient is:
o Artificial tear eye drops QID for 1 week (apply to right eye).
o Gut Spersallerg (Ophthalmic Decongestants, Anesthetics, Anti-
Inflammatory) TDS for 1 week (apply to right eye).
Health education given before discharge patient with next follow up.

Nursing intervention.

Make sure patient calm and comfortable during his time in clinic.
Monitor patient vital sign.
Give emotional support.
Give a hand during any procedure.

Health Education.

Ask patient to go back to emergency department or Eye clinic if persistent pain,

bleeding, abnormal discharge, loss of vision occur.
Ask patient to avoid exposure to the cause or allergen.
Advice patient to regularly rinse their eyes using saline eyewash.
Keep eyes clean.
Avoid rubbing the eyes.
Take prescribed medications or eye drops as ordered.
Advice patient to not share towels, washcloths, or eye drops with anyone who has an
eye infection (bacterial conjunctivitis etc).
Do not use contact lenses or makeup until your symptoms resolved.
 Always wash hands after and before touching your face/eyes.
Apply cool or warm compresses if needed.
Advice patient to come for next follow up.

Reflective report.

In doing this case clerking, I have learned that there are many types of conjunctivitis, such as
allergic conjunctivitis, bacterial conjunctivitis, viral conjunctivitis and many more. Each of them
had their own special characteristic and had their own management. I also have learned how to
do visual acuity and basic eye examination using Ophthalmoscope. Furthermore, I also have a
change to learn and use tonometer machine to check level of intraocular pressure of the eyes
and using funduscopy to check fundus and optic disc of the eyes. Other than that, I also have
learn how and what health education to be given for conjunctivitis cases.