History of Present Illness (HPI)
The patient is a 4-year-old female patient who was referred to the pediatric ophthalmology and strabismus clinic at the University of Iowa for evaluation of a lump on the right lower eyelid. The parents first noticed it about two weeks ago. There was no recollection of previous trauma or insect bites in the area. They were seen at their local family care center and were prescribed oral Bactrim (trimethoprim/sulfamethoxazole). The patient had been taking the medication for four days, but there was no improvement in the area. The patient was behaving well and did not report any pain in the area.
Past Ocular History
No other ocular history.
Family Ocular History
Negative for ocular problems.
Medical History
Normal growth and development with no history of illness.
Ocular Medications
Bactrim Suspension (trimethoprim/sulfamethoxazole) 10 ml, orally (PO), twice a day (BID) for 10 days, currently on the fourth day.
Systemic Medications
None.
Social History
The patient lives at home with her parents. She does not have any siblings. The family recently moved from Florida to Iowa.
Ocular Examination
Visual acuity (LEA symbols) without correctionRight eye (OD): 20/30Left eye (OS): 20/25
Pupils: 4 mm in the dark, 2 mm in the light, without relative afferent pupillary defect in both eyes (OU).
Alignment: Orthophoric
Extraocular Movements: Full range of motion
Slit Lamp Examination
OD
OS
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| The initial presentation revealed a firm nodule measuring 1.0 mm x 0.7 mm on the lateral aspect of the right lower eyelid with superficial skin rupture and erythema. |
Diagnosis:
The patient has been diagnosed with a chalazion on the right lower eyelid.
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