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Assessment:
The patient presents with eye redness, discharge, and itching, consistent with conjunctivitis. The discharge is [watery/purulent], suggesting [viral/bacterial] etiology. The patient [does/does not] wear contact lenses, which increases the risk for bacterial infection, particularly with Pseudomonas species. No signs of vision loss or severe eye pain. Differential diagnosis includes allergic conjunctivitis, viral conjunctivitis, bacterial conjunctivitis, and iritis.
Plan:
For bacterial conjunctivitis, prescribe antibiotic eye drops (e.g., polymyxin B/trimethoprim or ciprofloxacin). For viral conjunctivitis, recommend supportive care with cool compresses and artificial tears. Advise strict hand hygiene and avoiding touching the eyes to prevent spread. If allergic conjunctivitis, recommend antihistamine eye drops and allergy avoidance measures. If the patient wears contact lenses, instruct them to discontinue use until symptoms resolve and discard old lenses. Follow up if symptoms worsen or do not improve in 3-5 days, or if vision changes occur. Refer to ophthalmology if needed.
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