Care plan for a patient with conjunctivitis?

Patient: 35-year old female with acute conjunctivitis.

Chief Complaint: Red, itchy, and watery eyes.

History of Present Illness: The patient reports that she woke up this morning with redness, itching, and watering in both eyes. She denies any eye pain, discharge, or blurred vision. She reports that she has been wearing contact lenses for the past 5 years and has never had any problems with them before. She states that she has not been exposed to any allergens or irritants that she is aware of.

Past Medical History: The patient reports that she has a history of seasonal allergies.

Social History: The patient is a married mother of two young children. She works as a teacher.

Medications: The patient is currently taking oral antihistamines for her seasonal allergies.

Physical Examination:

Eyes:

- Visual acuity: 20/20 in both eyes

- Pupils: Equal, round, and reactive to light

- Extraocular muscles: Full and intact

- Conjunctiva: Hyperemic and edematous

- Cornea: Clear

- Sclera: White

Other:

- No other abnormalities noted

Laboratory Studies:

Conjunctival swab: Negative for bacteria and fungi

Viral culture: Pending

Diagnosis:

Acute conjunctivitis, viral

Treatment Plan:

- Artificial tears

- Cold compresses

- Topical antibiotic ointment

- Oral antihistamines

- Avoid wearing contact lenses until the infection has cleared

Prognosis:

Good. The patient should recover completely within 1-2 weeks.

Education:

The patient was educated on the following topics:

- The cause and symptoms of conjunctivitis

- The treatment plan

- The importance of good hand hygiene to prevent the spread of infection

- The importance of avoiding contact with allergens and irritants

- The importance of following up with her healthcare provider if her symptoms do not improve

Illness - Related Articles