Chapter 6: Special Sensory Organs: Eye and Ear | Maria Jacobowitz's Chart Note


Patient Name: Jacobowitz, Maria
ID Number: MJ3321
Examination Date: August 12, 20xx

This 32-year-old female was struck in the left eye by the slats of a mini-blind, lacerating (scratching or tearing) the sclera. Mild pain was noted but no immediate visual problems, no photophobia (extreme sensitivity to light), and no blurred vision.

There appears to be an abrasion of the left sclera with surrounding subconjunctival (below the membrane that lines the eyelids) hematoma. Pupils are equal, regular, and reactive to light. There does not appear to be any involvement of the cornea. Fluorescein stain shows some mild uptake over the injury site.

abrasion, left eye.

Patient should apply Garamycin® ophthalmic solution (antibiotic medication), 1–2 drops to left eye every 4 hours for 3 days. Recheck if problem continues or symptoms worsen.

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