What history taking and physical exam should be done for an active duty male in his 30s presenting with right eye conjunctivitis (pink eye)?

History Taking for Right Eye Conjunctivitis in Active Duty Male

Begin by documenting the character of discharge (purulent, mucopurulent, or watery), duration and time course of symptoms, and whether symptoms are unilateral or bilateral, as these are the most critical differentiating features between bacterial, viral, and allergic etiologies. 1

Essential Symptom Assessment

• Discharge characteristics: Mattering and adherence of eyelids upon waking strongly suggests bacterial conjunctivitis, while watery discharge with recent upper respiratory infection indicates viral etiology 2, 3
• Itching presence or absence: Intense itching is the most consistent sign of allergic conjunctivitis, while lack of itching favors bacterial cause 1, 3
• Pain severity: Moderate to severe pain is a red flag requiring immediate ophthalmology referral for possible corneal involvement or more serious intraocular pathology 2, 4
• Visual changes: Any blurred vision or visual loss must be documented as this indicates potential corneal involvement 1, 2
• Photophobia: Document presence as this suggests corneal epithelial defects or anterior chamber inflammation 1

Exposure and Risk Factor History

• Recent contact with infected individuals: Critical for identifying viral or bacterial sources, particularly in military barracks or training environments 1, 2
• Contact lens wear: Document lens type, hygiene practices, and wearing schedule—contact lens wearers require antibiotic treatment and have higher risk of serious complications 1, 5
• Recent ocular trauma or surgery: Any mechanical, chemical, or ultraviolet exposure must be documented 1
• Sexual activity and genitourinary symptoms: In active duty males, specifically ask about urethral discharge, dysuria, or recent sexual contacts, as chlamydial and gonococcal conjunctivitis require systemic treatment 1, 6

Medical and Medication History

• Immunocompromised status: HIV, immunosuppressants, or chemotherapy increase risk of severe complications 1
• Allergy history: Document asthma, eczema, or atopy which suggest allergic etiology 1, 3
• Current medications: Both topical and systemic medications, particularly corticosteroids 1
• Previous episodes: History of recurrent conjunctivitis helps guide diagnosis 1

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Physical Examination for Right Eye Conjunctivitis

The examination must include visual acuity measurement, preauricular lymph node palpation, external examination of eyelids and discharge, and slit-lamp biomicroscopy with specific attention to corneal clarity and conjunctival reaction pattern (follicular versus papillary). 1, 2

Initial Assessment

• Visual acuity: Always measure and document best-corrected visual acuity at distance—this is mandatory for assessing severity 2, 4
• Preauricular lymphadenopathy: Palpate for enlarged nodes, which are common in viral and chlamydial conjunctivitis but rare in bacterial 1, 2

External Examination

• Eyelid assessment: Document swelling, discoloration, mattering, adherence of lids, ulceration, or vesicles 1, 2
• Skin examination: Look for rosacea, eczema, or seborrhea which may indicate underlying dermatologic conditions 1
• Discharge character: Purulent discharge suggests bacterial, mucopurulent suggests chlamydial, and watery suggests viral or allergic 2, 3

Slit-Lamp Biomicroscopy Findings

• Conjunctival reaction pattern: Follicular reaction (particularly on inferior tarsal conjunctiva) indicates viral or chlamydial etiology, while papillary reaction suggests bacterial or allergic 1
• Distribution of injection: Document whether diffuse, sectoral, or quadrantic involvement 1
• Eyelid margin examination: Assess for inflammation, meibomian gland dysfunction, crusting, or blood-tinged debris 1
• Corneal examination: This is critical—document corneal clarity and explicitly note presence or absence of infiltrates, ulcers, or epithelial defects, as corneal involvement requires immediate ophthalmology referral 2, 5
• Anterior chamber assessment: Check for inflammatory reaction or synechiae which indicate more serious intraocular pathology 1

Critical Red Flags Requiring Immediate Ophthalmology Referral

Document presence or absence of:

• Visual loss or moderate-to-severe pain 2, 5
• Corneal infiltrate or ulcer 2, 5
• Copious purulent discharge suggesting gonococcal infection 2, 5
• Contact lens wear with conjunctivitis 5
• Recent ocular surgery 2
• Vesicular rash on eyelids or nose suggesting herpes simplex virus 5

Special Considerations for Active Duty Military

• Occupational exposures: Document exposure to smoke, chemicals, or environmental irritants in training or deployment settings 1
• Sexual history: Given the military population, specifically document and consider sexually transmitted infections—gonococcal and chlamydial conjunctivitis require systemic antibiotics and partner notification 1, 6
• Return-to-duty implications: Bacterial conjunctivitis with topical antibiotics allows earlier return to work compared to untreated cases 3, 7