Alejandra was 7 years old with beautiful, dark brown hair and even darker eyes. Her mother, who only spoke Spanish, and the patient’s slightly older brother accompanied her. Alejandra spoke some English, but she deferred most of the history to her mother due to pain and her age. Our conversation, which involved using a translator on the phone, felt repetitive and circuitous until finally a story began to form.

She had been an otherwise healthy child. About a week earlier, she had developed rhinorrhea and a mildly productive cough, which her mother attributed to cold. A few days into her symptoms, she developed some redness and a little bit of drainage from her eyes. Being concerned for a bacterial infection, they presented to the emergency room for care. After waiting for several hours there, she was examined and given ciprofloxacin drops for a diagnosis of bacterial conjunctivitis. Shortly after, her eyes became redder and painful, and she developed photophobia. She denied any fevers, periorbital edema or vision changes. 

During my own exam of her eyes, I couldn’t detect drainage, but I winced with her as her eyes profusely watered against the light I shone to check her pupils. Her conjunctiva was injected diffusely. No hand or feet swelling. No rash, no mucositis. Her vision was 20/20.  

I was concerned for her. Being only a few months into working at the urgent care during my third year of residency, I excused myself from the room to turn where I usually do in uncertain clinical situations — a more experienced physician and an American Family Physician article. Given the prevalence of conjunctivitis, I had reviewed the condition multiple times in the prior weeks, but somehow seeing the algorithm and evidence in front of me had a way of grounding my thoughts.