Extended SOAP Note for Bacterial Conjunctivitis
Elaine Calana
South University
August 10, 2017
SOAP Evaluation
Sign and symptoms/Clinical Presentation:
32 year old Hispanic female presented today with chief complaint of, “I think I have pink eye. My right eye is red and has been really itchy.” Patient reported that her symptoms began 3 days ago which she thought nothing if it until she woke up this morning. Upon waking, patient stated that her right eye was swollen and that there was a greenish color of discharge coming from her right eye. Patient admitted to using cold compress when symptoms began which provided some relief; however, when she went to work this morning her supervisor said that she had to get seen my her doctor prior to returning back to work.
She is currently only taking a multivitamin, daily and has NKDA or food sensitivities. Patient was involved in a MVA in 2013 but indicated there she did not sustain any major trauma. Patient admits to have a history of depression in her past and was placed on medication which she unsure of the type given. Patient was hospitalized after the live births of her children and had ablation performed on an outpatient basis in 2015. Patient has a family history of hypertension, diabetes, alcoholism and drug addiction from her mother and father. Patient is a single mom working full time as a daycare provider and enjoys time spent with family and friends. She admitted to the use of illicit drugs in her past but has been clean and sober for 6 years and admits to consuming a glass or two of wine nightly. Otherwise, patient is of overall great health.
Diagnostic workup:
Physical examination indicated right eye erythematous with mucopurulent discharge; matted eyelid; normal visual acuity; cornea clear bilaterally. No lab or special diagnostic test were performed.
Differential Diagnosis:
Viral Conjunctivitis is a highly contagious acute conjunctival infection usually caused by adenovirus. Symptoms include irritation, photophobia, and watery discharge. Patient did not display photophobia or watery discharge.
Allergic Conjunctivitis is caused by environmental factors such as pollen, dust mites, pet dander, and mold; just to name a few. Typical signs and symptoms of allergic conjunctivitis consist of redness, itchiness and watery discharge in both eyes, oppose to unilateral and is often accompanied by acute discomfort in bright sunlight light (photophobia). The conjunctiva itself may become very swollen and look light purple, and this may interfere with clarity of vision. ROS and physical exam did not indicate this type of conjunctivitis.
Uveitis is often idiopathic but may be triggered by genetic, traumatic, immune, or infectious mechanisms. Signs and symptoms of uveitis include pain, redness, photophobia, blurred vision, and increased lacrimation.
Final Diagnosis:
Acute bacterial conjunctivitis typically presents with burning, irritation, tearing and, usually, a mucopurulent or purulent discharge. Patients with this condition often report that their eyelids are matted together on awakening. Conjunctival swelling and mild eyelid edema may be noted. The symptoms of acute bacterial conjunctivitis are far less severe, less rapid in onset, and progress at a much slower rate than those other types of conjunctivitis (Azari & Barney, 2014). Upon physical exam, patient’s right eye erythematous with mucopurulent discharge and matted eyelid. As per the subjective assessment, patient noted that her right eye is itchy and red and had greenish discharge.
Management:
Patient was prescribed azithromycin 1% one drop two times daily (administered eight to 12 hours apart) for two days, then one drop daily for five days; cost of generic brand $82 for 5 mL (Cronau, Kankanala, & Mauger, 2010). Hence, patient was also educated on the importance of not spreading it to others is imperative. Make sure all medication being prescribed is completed, as well as instruct patient how to effectively apply eye drops. Practice good hygiene, such as washing hands properly and often. Other preventive measures to educate patient on is to change pillowcases frequently, don’t share eye cosmetics, towels or handkerchiefs, keep hands away from the eyes, and replace eye cosmetics regularly (Dunlop & Wells, 2015). Don not return back to work until symptoms have resolved.
Patient was also advised on holistic approaches to the management of her bacterial conjunctivitis. These consist of herbal compress, such as a cold Chamomile tea bag on eyes to reduce swelling and redness, and discharge. Another option would be to rub a small amount from the inside of an aloe leaf on the inside of upper and lower lids to soothe pain and reduce redness.
Patient was also advised to call office if symptoms get worse, develop a fever and ear pain, notice tiny bumps or spots of blood on your eye, if vision becomes an issue and/or just have questions or concerns about your condition, care, or medication. If symptoms worsen, a referral to an ophthalmologist may be needed for further testing and evaluation.
Disease Background
Anatomy:
The conjunctiva is the fine mucous membrane which covers and joins the anterior surface of the eyeball to the posterior surface of eyelid. This translucent membrane lines the white part of the eye starting at the edge of the cornea (limbus) and runs behind the eye to cover the anterior part of the sclera. It then flows, loops forward, and forms the inside surface of the eyelids. At the medial canthus the conjunctiva fold thickens, which is called the semilunar fold (Haq, Wardak, & Kraski, 2013).
Etiology:
Bacterial conjunctivitis most often occurs in otherwise healthy individuals. Risk factors include exposure to infected individuals, fomite contact (e.g., towels, napkins, pillow cases, slit-lamp chin rests and handles), contact lens wear, sinusitis, immunodeficiency states, prior ocular disease, trauma, and exposure to agents of sexually transmitted disease at birth (Azari & Barney, 2014).
Pathophysiology:
The surface tissues of the eye and the ocular adnexa are colonized by normal flora such as streptococci, staphylococci, and corynebacteria. Alterations in the host defense, in the bacterial titer, or in the species of bacteria can lead to clinical infection. Alteration in the flora can also result from external contamination (e.g., contact lens wear, swimming), the use of topical or systemic antibiotics, or spread from adjacent infectious sites (e.g., rubbing of the eyes) (Yeung, 2017).
The primary defense against infection is the epithelial layer covering the conjunctiva. Disruption of this barrier can lead to infection. Secondary defenses include hematologic immune mechanisms carried by the conjunctival vasculature, tear film immunoglobulins, and lysozyme and the rinsing action of lacrimation and blinking (Yeung, 2017).
Epidemiology:
According to authors Azari and Barney (2014), conjunctivitis affects many people and imposes economic and social burdens. It is estimated that acute conjunctivitis affects 6 million people annually in the United States (Azari & Barney, 2014). The cost of treating bacterial conjunctivitis was estimated to be $377 million to $857 million per year (Azari & Barney, 2014). A majority of conjunctivitis patients are initially treated by primary care physicians rather than eye care professionals. Approximately 1% of all primary care office visits in the United States are related to conjunctivitis. Approximately 70% of all patients with acute conjunctivitis present to primary care and urgent care (Azari & Barney, 2014).
Prognosis:
The prognosis for complete recovery without sequelae is excellent in bacterial conjunctivitis, as long as the cornea is not involved. Most benign cases are treated with topical antibiotics or self-resolve (Dunlop & Wells, 2015) Bacterial conjunctivitis generally resolves within 1-2 weeks without treatment. Complications are expected to develop only in cases caused by extremely pathogenic bacteria, such as C trachomatis or N gonorrhoeae (Dunlop & Wells, 2015; Cronau, Kankanala, & Mauger, 2010).
Patient Education:
To counteract bacterial conjunctivitis, patient education ought to incorporate good hygiene (e.g., washing hands with cleanser and water) and shirking of touching the eyes, particularly after presentation to conceivably irresistible individuals. Legitimate contact lens care incorporates avoidance of contact lens wear while sleeping and appropriate cleaning and disposing of the lens and contact lens cases.
Patients with bacterial conjunctivitis ought to be told not to touch their eyes and to abstain from sharing fomites. They ought to likewise be instructed with respect to their irresistible nature to forestall transmission and the significance of completing their anti-toxin regimen. Patients with bacterial conjunctivitis who wear contact focal points ought to be told to stop contact focal point utilize and to dispose of their utilized contact focal points, open contact focal point arrangements, utilized contact focal point cases, and utilized cosmetics and cosmetics brushes (Haq, Wardak, & Kraski, 2013).
Treatment Evaluation
Approach considerations/ Guidelines and literature referenced:
Preferred Practice Pattern guidelines should be clinically relevant and specific enough to provide useful information to practitioners. Where evidence exists to support a recommendation for care, the recommendation should be given an explicit rating that shows the strength of evidence. To accomplish these aims, methods from the Scottish Intercollegiate Guideline Network1 (SIGN) and the Grading of Recommendations Assessment, Development and Evaluation2 (GRADE) group are used. GRADE is a systematic approach to grading the strength of the total body of evidence that is available to support recommendations on a specific clinical management issue. Organizations that have adopted GRADE include SIGN, the World Health Organization, the Agency for Healthcare Research and Policy, and the American College of Physicians (American Academy of Ophthalmology Cornea/External Disease Panel, 2013).
As per the American Academy of Ophthalmology guidelines (2013), mild bacterial conjunctivitis is generally self-restricted, and it ordinarily settle precipitously without particular treatment in immune-competent adults (Sheikh, Hurwitz, Van Schayck, McLean, & Nurmatov, 2012). Use of topical antibacterial treatment is related with before clinical and microbiological reduction contrasted with fake treatment in days 2 with 5 of treatment (Sheikh, Hurwitz, Van Schayck, McLean, & Nurmatov, 2012). These points of interest hold on finished days 6 to 10, however the degree of advantage over fake treatment diminishes over time (American Academy of Ophthalmology Cornea/External Disease Panel, 2013). The decision of anti-toxin is typically empiric. Since a 5-to-7-day course of a wide range topical anti-toxin is typically powerful, the most helpful or slightest costly choice can be chosen; there is no clinical confirmation recommending the predominance of a specific anti-toxin (American Academy of Ophthalmology Cornea/External Disease Panel, 2013).
Serious bacterial conjunctivitis is portrayed by extensive purulent release, torment, and checked aggravation of the eye. Conjunctival societies and slides for Gram recoloring ought to be acquired if gonococcal disease is a plausibility. In these cases, the decision of anti-infection is guided by the aftereffects of lab tests. Methicillin-safe Staphylococcus aureus has been detached with expanding recurrence from patients with bacterial conjunctivitis (Anstead, Quinones-Nazario, & Lewis II, n.d). Increasing colonization of MRSA has been found in nursing home residents, (Stockman, 2009) and the occurrence of group procured MRSA diseases likewise has risen. Methicillin-safe S. aureus living beings are impervious to numerous economically accessible topical antibiotics. (Anstead, Quinones-Nazario, & Lewis II, n.d). Systemic anti-toxin treatment is important to treat conjunctivitis because of Neisseria gonorrhoeae and Chlamydia trachomatis. Topical treatment, while a bit much, is generally additionally utilized. Saline lavage may advance solace and more quick determination of aggravation in gonococcal conjunctivitis. In the event that corneal association is available, the patient ought to likewise be dealt with topically concerning bacterial keratitis
Patients with gonococcal conjunctivitis ought to be seen every day until determination of the conjunctivitis. At each subsequent visit, an interim history, visual sharpness estimation, and opening light biomicroscopy ought to be performed. For different sorts of bacterial conjunctivitis, patients ought to be approached to return for a visit in 3 to 4 days in the event that they take note of no change. N. meningitis ought to be disposed of as the causative life form before presuming that N. gonorrhoeae is dependable (American Academy of Ophthalmology Cornea/External Disease Panel, 2013).
Complications:
Most cases of bacterial conjunctivitis in adults have no really serious complications, however, some rare complications associated with bacterial conjunctivitis include corneal ulceration, and blepharitis and Meibomian gland inflammation may complicate chronic bacterial conjunctivitis in some individuals.
Health Promotion & Risk Reduction:
Infected individuals should be counseled to wash hands frequently with soap and water (as opposed to sanitizer only) and use separate towels, and to avoid close contact with others during the period of contagion. Avoiding contact with others is especially important for individuals in professions with high potential for transmission, such as health care workers and child care providers. While the exact length of the period of infectivity is variable, many consider 7 days from the onset of symptoms as the contagious period, because the recovery of virus from infected cases drops off after 7 days of infection. However, other studies have suggested that patients should be considered potentially contagious for at least 10 to 14 days.
Medicolegal Concerns:
Medicolegal concerns do arise in connection with bacterial conjunctivitis. As with all medical practice, careful discussion and documentation is paramount. A few general guidelines are helpful, as follows:
• Know the differential diagnosis.
• Perform an eye examination and, in particular, document that keratitis, iritis, and acute
glaucoma have been ruled out.
• Always document the best corrected visual acuity in each eye.
• Determine the absence of glaucoma on every visit or the inability to safely do so. A
simple ballpark bidigital applanation of each globe through the closed upper lid provides
a useful and legally protective assessment of intraocular pressure (IOP). This assessment
can be performed in immediate proximity to the digital assessment for preauricular
lymphadenopathy, accompanied by thorough physician handwashing thereafter.
• Be aware of more unusual conditions, such as carotid-cavernous fistula.
• Always consider Chlamydia or N gonorrhoeae in the differential diagnosis. Be sure to
treat systemically and ask for advice from other specialists when needed (Azari & Barney, 2014).
Future Research needed:
Much research has suggested that health care professionals treating patients for bacterial conjunctivitis are prescribing the wrong medications. These antibiotics being prescribed are said to increases cost for patients, raises resistance to the antibiotic, and contributes to the rise of dangerous superbugs. According to one study, the authors believe that many health care professionals are misdiagnosing patients and are being challenged by differentiating the symptoms of bacterial conjunctivitis from viral and allergic forms (Shekhawat, Shtein, Blachley, & Stein, 2017). More research in differentiating the symptoms between various conjunctivitis are imperative so that the right form of medication is delivered.
Consultation:
Since bacterial conjunctivitis is self-limiting, but of these cases do not require a consultation. However, if symptoms worsen then a referral to an ophthalmologist is recommended.
Long term monitoring:
No long-term monitoring is necessary unless there are underlying complications or the patient’s symptoms are recurrent and don’t go away.
Ethical and cultural consideration:
It is always important to do no harm to patients and many of them may have a problem with having cultures of their eye taken for a formal diagnosis. However, when issues such as this arise it is imperative that the healthcare professional adhere to their code of ethics and to adhere to the culture of their patient’s beliefs, whether based on religion, social class, and gender.
Cost:
Treating bacterial conjunctivitis incur direct and indirect costs. According to the results of one study, they determined that the estimated direct and indirect cost of treating patients with bacterial conjunctivitis in the United States of $ 491 million and $97 million, respectively, for a total cost of $ 589 million (Smith & Waycaster, 2009).
Critical Reflection of interaction and investigation
The patient interaction was pretty straightforward and a diagnosis of bacterial conjunctivitis was final. Although no lab or diagnostic testing was performed, the ROS and the physical examination helped to diagnose the patient. In terms for the reason of not performing any diagnostic workup is based on the fact that in most cases for diagnosing bacterial conjunctivitis in adults are elf-limiting and are typically only used in immune compressed individuals with other underlying conditions.
Test Questions
1. What is bacterial conjunctivitis?
2. How is bacterial conjunctivitis diagnosed?
3. What is the best treatment for bacterial conjunctivitis?
4. What are the guidelines for treating bacterial conjunctivitis?
5. When should a referral to an ophthalmologist be made?
References
American Academy of Ophthalmology Cornea/External Disease Panel. (2013). Conjunctivitis PPP - 2013 - American Academy of Ophthalmology. Retrieved August 10, 2017, from https://www.aao.org/preferred-practice-pattern/conjunctivitis-ppp--2013#references
Anstead, G. M., Quinones-Nazario, G., & Lewis II, J. S. (n.d.). Treatment of Infections Caused by Resistant Staphylococcus aureus. Methicillin-Resistant Staphylococcus aureus (MRSA) Protocols, 227-258. doi:10.1385/1-59745-468-0:227
Azari, A. A., & Barney, N. P. (2014). Conjunctivitis: A Systematic Review of Diagnosis and Treatment. JAMA, 310(16), 1721-1729. doi:10.1001/jama.2013.280318
Cronau, H., Kankanala, R. R., & Mauger, T. (2010). Diagnosis and Management of Red Eye in Primary Care. Am Fam Physician, 8120112015, 137-144. Retrieved from http://www.aafp.org/afp/2010/0115/p137.html
Dunlop, A. L., & Wells, J. R. (2015). Approach to Red Eye for Primary Care Practitioners. Primary Care: Clinics in Office Practice, 42(3), 267-284. doi:10.1016/j.pop.2015.05.002
Haq, A., Wardak, H., & Kraski, N. (2013). Infective Conjunctivitis – Its Pathogenesis, Management and Complications. Common Eye Infections. doi:10.5772/52462
Sheikh, A., Hurwitz, B., Van Schayck, C. P., McLean, S., & Nurmatov, U. (2012). Antibiotics versus placebo for acute bacterial conjunctivitis. Cochrane Database of Systematic Reviews. doi:10.1002/14651858.cd001211.pub3
Shekhawat, N. S., Shtein, R. M., Blachley, T. S., & Stein, J. D. (2017). Antibiotic Prescription Fills for Acute Conjunctivitis among Enrollees in a Large United States Managed Care Network. Ophthalmology, 124(8), 1099-1107. doi:10.1016/j.ophtha.2017.04.034
Smith, A. F., & Waycaster, C. (2009). Estimate of the direct and indirect annual cost of bacterial conjunctivitis in the United States. BMC Ophthalmology, 9(1). doi:10.1186/1471-2415-9-13
Stockman, J. (2009). Invasive Methicillin-Resistant Staphylococcus aureus Infections in the United States. Yearbook of Pediatrics, 2009, 260-263. doi:10.1016/s0084-3954(08)79046-8
Yeung, K. K. (2017). Bacterial Conjunctivitis: Practice Essentials, Background, Pathophysiology. Retrieved from http://emedicine.medscape.com/article/1191730-overview