Download WSHIMA - Case 8: Clinic Visit Chief Complaint New Patient Referral

WSHIMA - Case 8: Clinic Visit
Chief Complaint
New Patient
Referral for punctal stenosis right eye
HPI: 10 year old male who experienced a chemical injury to the Right ocular surface 2 months
ago. He was cutting open a battery to "see what was inside" when the battery acids splashed into
the right eye. It was copiously irrigated as soon as possible; there was no corneal injury, but the
medial canthal lids were burned by the chemical and have subsequently scarred. He experiences
epiphora from the right eye 100% of the time, and always has to carry tissues. No pain or
irritation symptoms.
ROS: All systems reviewed, negative except as noted above and per HPI.
Hx:
As above. Otherwise negative.
Meds:
None. Has stopped ofloxacin, cyclopentolate, and FML.
PMHx:
Past Medical History
Chemical burn of eye or adnexa
Acidic Burn, Right eye. ; Refractive error