CHA AHP

Running head: Eye and Ear SOAP 1

Subjective:

ID: SM, female, 26

Source: Patient, reliable historian

CC: “My eyes are red and irritated. I think I have pink eye!”

HPI: Patient reports that she is generally in good health. She reports that she woke up

yesterday with sticky eyelids that further presented with yellow colored drainage. Denies pain to

eyes. Patient reports mild itching and burning and reports a sensation of grittiness. Reports

redness and swelling to her to her R eyelid. Reports an onset of yesterday 10.13.2016, location of

her right eyelid, duration of one day, aggravating factor of factor of rubbing her eye, and an

alleviating factor of a cold compress as needed. States that she would like her eyes and ears

checked.

PMH:

Current Medications: Hydrocortisone cream OTC as needed during eczema flare ups.

Last use: 9.13.2016 at 9am for a mild flare up on the forearms.

Disease Processes: PCOS well controlled by lifestyle management. Eczema is controlled

at most times but flares up from time to time. The last flare up was 9.13.16, it was a mild

flare up per patient’s report.

Hospitalizations and Surgeries: none

Allergies: No known drug, food, or environmental allergies.

FH: Non-contributory.

Running head: Eye and Ear SOAP 2

ROS: eye: Patient reports that she has 20/20 vision without corrective lenses. Denies blurred

vision, history of glaucoma, and diplopia. Denies history of cataracts. Denies tanning booth use.

Denies use of tanning booths. Reports mild blurring of vision when drainage is present. Ears:

Denies any pain to the ear. Denies presence of any hearing loss or drainage. Patient denies any

tinnitus or feelings of vertigo. Reports that she cleans her ears with a warm towel and denies use

of q-tips or hair pins to scratch ear. Denies use of hearing aid.

Psych/social: College student. Lives with parents and insured under their policy. Denies

tobacco, ETOH or illicit drug use. States is currently dieting- eating low carb. States is stressed

by school but feels she is coping well. Denies domestic or other violence concerns.

Immunizations: Up to date for all CDC recommended immunizations for her age. Last

Tdap-2016. Flu Vaccine Oct 2016.

Objective:

BP: 119/ 67 left arm P: 77 R: 15 Temp: 98.8 Height: 5’7 Weight: 185 Ibs BMI: 29

Eye and ear: Eyebrows are symmetrical, with fine hair. Palpebral slants symmetrical, no ptosis

noted. Orbital area is free of edema and sagging tissue. Eyelids are reddened and slightly

edematous. Eyelashes present evenly distributed with dried yellowish drainage noted.

Conjunctiva to right eye is reddened with drainage present, left eye is clear. Bilateral sclera are

white. Cornea covers the pupil and iris. Anterior chamber of eye is flat. Puncta of right eye is

reddened, left eye puncta is white. Pupils are symmetrical, round and 3mm in size. Snellen chart

used to assess visual acuity with 20/20 as result. Fields of vision full by confrontation. Pupils are

equal and reactive to light and accommodation. Convergence present upon assessment. Iris is

clearly defined. EOMs intact bilaterally. No nystagmus noted except with extreme lateral gaze.

Running head: Eye and Ear SOAP 3

No strabismus noted. Red reflex noted bilaterally. Optic disc margins well demarcated. No

nicking of the veins or arterial venous crossings noted. Macula noted lateral to optic disc. No

hemorrhaging or exudate noted on retina. External ear is free of drainage or tenderness. Acuity

good to whispered voice. Tympanic membrane presents as a pearly gray color free of bulging or

perforation. Cone of light noted at 5’oclock position in right ear and 7'oclock in left ear. Handle

of malleus noted at 1’oclock position in right ear and 11'oclock position in left ear. No

lateralization with Weber. AC>BC 2:1 with Rinne test.

Assessment: acute unilateral bacterial conjunctivitis.

Differential diagnosis: viral conjunctivitis, acute iritis, and acute closed angle glaucoma.

Plan: Gentamicin ophthalmic ointment- apply ½ ribbon to the affected eye bid

 If the infection does not subside, the next step would be to obtain and culture of the

specimen to choose a more appropriate antibiotic or to rule in a viral cause.

 Educate the patient on the highly contagious nature of bacterial conjunctivitis,

encouraging the avoidance of sharing toiletries and towels with family members to

prevent the spread of the infection.

 Encourage her to avoid rubbing her eye with her bare hands and touching her other eye or

other objects.

 Emphasis on hand hygiene.

Reference:

Watkinson, S. (2013). Assessment and management of patients with acute red eye. Nursing Older

People, 25(5), 27-34.