Diagnosis Choose one Title
Conjunctival abrasion
Laterality Choose one First line
Right eye Left eye Both eyes
Mechanism Choose one
From a fingernail scratch From a branch or plant From a foreign body in the eye Related to contact lens wear From a high-speed object such as metal from hammering or a lawnmower After a chemical splash, with the eye irrigated in clinic From a toy or other object Mechanism unknown
Diagnosis basis Choose one
Fluorescein uptake on the cornea consistent with a corneal abrasionDefault Fluorescein uptake on the conjunctiva with a clear cornea
Exam details Choose any
Visual acuity normal Topical anesthetic drops used in clinic for the exam
Foreign body Choose one
No foreign body seen, including under the upper eyelid after eversionDefault Superficial foreign body removed with irrigation Superficial foreign body removed with a moistened cotton swab Embedded foreign body that could not be removed
Concerning findings present Choose any
decreased vision blood behind the cornea a white spot or cloudiness of the cornea an irregular pupil or other sign of a penetrating injury
Concerning findings absent Choose any
decreased visionDefault blood behind the corneaDefault white spot or cloudiness of the corneaDefault irregular pupil or other sign of a penetrating injuryDefault
Antibiotic Choose one
Started Erythromycin ointment to prevent infectionDefault Started Polytrim drops to prevent infection Started Ciprofloxacin drops given contact lens wear Antibiotic choice deferred to ophthalmology today
Care Choose any
Avoid rubbing the eyeDefault Recommended tylenol or motrin for painDefault
Contact lenses Choose any
No contact lenses until fully healed
Referral Choose one
Urgent ophthalmology evaluation arranged today
Disposition Choose one
Sent to the emergency department given concern for a penetrating eye injury
Follow-up Choose one
if not improving in 1-2 days, with ophthalmology referral if still not healingDefault in 1-2 days after the specialist visit as needed
Counseling paragraph Choose one Paragraph
Most corneal abrasions heal within 1 to 2 days, and the eye may be painful, watery, and sensitive to light until then; the antibiotic helps prevent infection while it heals. Recommended supportive care with OTC medications as needed with an emphasis on tylenol or motrin for pain, sunglasses for light sensitivity, and not rubbing the eye. Return precautions given including worsening pain, vision change, a feeling that something is still in the eye, pus or increasing redness, pain that is not improving, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with plan. Answered all questions.Default A scratch on the white of the eye usually heals within a few days and does not affect vision; the antibiotic helps prevent infection while it heals. Recommended supportive care with OTC medications as needed with an emphasis on tylenol or motrin for pain and not rubbing the eye. Return precautions given including worsening pain, vision change, a feeling that something is still in the eye, pus or increasing redness, pain that is not improving, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with plan. Answered all questions. Because of today's findings, an eye doctor needs to examine the eye today. Recommended supportive care with OTC medications as needed with an emphasis on tylenol or motrin for pain and not rubbing the eye until then. Return precautions given including worsening pain, vision change, a feeling that something is still in the eye, pus or increasing redness, pain that is not improving, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with plan. Answered all questions.
Counseling Not in the note with these choices
Discussed the need for emergency evaluation today. Caregiver expressed understanding and agreement with plan. Answered all questions.
Note when inserted as is
Copy Use in Workspace
Corneal abrasion
• Fluorescein uptake on the cornea consistent with a corneal abrasion
• No foreign body seen, including under the upper eyelid after eversion
• No decreased vision, blood behind the cornea, white spot or cloudiness of the cornea, or irregular pupil or other sign of a penetrating injury
• Started Erythromycin ointment to prevent infection
• Avoid rubbing the eye
• Recommended tylenol or motrin for pain
• Follow up if not improving in 1-2 days, with ophthalmology referral if still not healing
Most corneal abrasions heal within 1 to 2 days, and the eye may be painful, watery, and sensitive to light until then; the antibiotic helps prevent infection while it heals. Recommended supportive care with OTC medications as needed with an emphasis on tylenol or motrin for pain, sunglasses for light sensitivity, and not rubbing the eye. Return precautions given including worsening pain, vision change, a feeling that something is still in the eye, pus or increasing redness, pain that is not improving, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with plan. Answered all questions.