Additional History:
The patient was born at full term via uncomplicated spontaneous vaginal delivery. The mother had routine prenatal care since nine weeks gestation. Apgar scores were 8 and 10 at 1 and 5 minutes respectively. The mother has a history of genital herpes for which she started prophylactic treatment of valacyclovir at 36 weeks of gestation. No active genital lesions were seen on pelvic exam prior to delivery of the patient. Third trimester GBS screening was negative. The patient received topical erythromycin following delivery. The mother denies any recent trauma to the eye. There is no history of recent fever, chills, or shortness of breath.
Physical Exam:
General appearance: Fussy infant with noticeably swollen eye OD > OS. No dysmorphic features. Breathing comfortably.
Vitals: Temp: 37C, BP: 93/60, HR: 125 bpm, RR 27, O2 sat: 99%, Weight: 8 lbs, Height: 80 cm
Head: Anterior and posterior fontanelle soft and open. Normocephalic. Atraumatic.
Neck: Soft and supple. No lymphadenopathy.
Eyes: Blink to light OU.
Crusting along both upper and lower eyelids OU. Mucopurulent discharge with RUL edema. Conjunctival injection OD>OS. Small lumps are seen on the palpebral conjunctiva of the lower eyelids bilaterally.
Cornea appears clear OU.
Red pupillary reflex OU.
Pupils are equal and reactive to light OU.
Eyes soft to palpation OU.
Cardiac: Normal S1/S2. No murmurs, rubs or gallops appreciated.
Lungs: Clear to auscultation bilaterally.
Abdomen: Normoactive bowel sounds. Umbilical stump clean, dry and intact.
Back: No tufts of hair seen along the spine.
GU: Patent anus. Normal external genitalia.
Extremities: No click heard or felt on Ortolani and Barlow maneuvers. Femoral pulses intact.
Reflexes: Soft and supple. No lymphadenopathy.
Skin: No rashes
Below is an external photo of the patient’s eyes:
Based on the physical exam findings, the pediatrician refers the patient to an ophthalmologist who sees the baby later that day.
Click here to move on!
Peds ophtho Case 5 Index
Peds Ophtho Case 5 Introduction