soap note

Name: NS

Date: 01/18/18

Time: 10:45 AM

Pt Encounter Number:

N/A

Age: 25

Sex: F

SUBJECTIVE

CC: 

  “My eyes are swollen, red and painful”

HPI: 

Patient is 25-year-old female came to the office today with chief complaint of bilateral eye redness accompanied by inflammation and itching with greenish discharge worsening in the morning when ayes are glued by the secretions. Patient states the complaint started three days ago with her left eye affected first, and the following day her right eye started with the same symptoms. Discomfort rated 4/10.

Medications:

None

PMH

- Appendectomy (2008)

Allergies:  NKDA, NKA to food, latex.

Medication Intolerance: None

Chronic Illnesses/Major traumas: None

Hospitalizations/Surgeries: Appendectomy (2008)

Immunizations: Up to date

Family History

Mother- 47 y/o: Healthy (Alive)

Father: 49 y/o: HTN (Alive)

Brother: 22 y/o: No health issues (Healthy)(Alive)

Maternal Grandmother 69 y/o- HTN (Alive)

Maternal Grandfather- 70 y/o HTN; Asthma (Alive)

Paternal Grandmother- 71 y/o HTN; Hypothyroidism (Alive)

Paternal Grandfather- 70 y/o Diabetes, Hypertension (Alive)

Social History

Smoking/Use Tobacco: No

Use Alcohol: No- Substance abuse/Use Drug: No

Violence or abuse in the home: (including physical, psychological or sexual abuse): No

Caffeine intake: No

Sexually active: Yes

Occupation: College Student

Marital status: Single

Live with: Family

Children: None

ROS

General

Negative (Night sweats, weakness, malaise, chills or fever)

Cardiovascular

Negative (Negative for chest discomfort, tachycardia or inflammation of lower extremities)

Skin

Negative (Negative for wounds, skin discolorations, rash, itching)

Respiratory

Negative (Shortness of Breath, Cough, Sputum, Wheezing, Pleuritic Pain, Snoring, Hemoptysis, Daytime sleepiness) 

Eyes

Positive (bilateral eye redness, pain and greenish discharge and eyelid swelling)

Negative (Vision change, Glasses/Contacts) 

Gastrointestinal

Negative (Nausea, Vomiting, Constipation, Bright red stool, Diarrhea, Heartburn, Melena, Increase Girt, Easy fullness, Hematemesis, Jaundice) 

Ears

Negative (Hearing Loss, Tinnitus, Discharge, Vertigo, Earache, Ear fullness) 

Genitourinary/Gynecological

Negative (Change in urine color, urgency, incontinence, foul smelling urine)

Nose/Mouth/Throat

Negative (Nose bleed, Sneezing, Stuffiness, Sinus pain, Sore Throat, Dysphagia, Running nose) 

Musculoskeletal

Negative (Joint or muscle pain or swelling)

Breast

Deferred

Neurological

Negative (Seizures, Syncope, Paresis, Speech difficulty, Tremor, Unsteady gait)

Heme/Lymph/Endo

Negative (Anemia. Easy bruising, Thrombocytopenia, Excessive bleeding, Transfusion reactions, Night sweats, Swollen glands, Increase thirst, Increase hunger, Cold or heat intolerance, Goiter, Hair loss)

Psychiatric

Negative (Depression, sleeping difficulties, suicidal ideation, Hallucinations)

OBJECTIVE

Weight: 120 Lbs      BMI: 20 (Normal)

Temp: 97.9

BP:120/76

Height: 5’05”

Pulse: 75

Resp: 18

General Appearance

Pleasant and well developed, Hispanic female, well-nourish, well groomed, normal body habitus, no deformities, gait is normal, posture is normal. Alert and oriented; answers questions appropriately.

Skin

Skin is warm and intact. Turgor is good. Capillary refill 2 seconds.

HEENT

Head is atraumatic and normocephalic. Pupils equal round and reactive to light and accommodation. Non-iceric sclera with red conjunctivas. Bilateral diffuse redness and discharge. Mild bilateral eyelids swelling. Negative for subconjunctival hemorrhage. Moist mucosa, normal tonsils and adenoids and normal tongue. Neck is supple, trachea is midline, no carotid bruit or masses.

Cardiovascular

Regular rate and rhythm, S1S2 normal, no murmurs, no gallops. Point of maximum impulse (PMI) @4TH intercostal/midclavicular line.

Respiratory

Symmetric chest wall. Respiration regular and easy; lungs clear to auscultation and normal percussion bilaterally.

Gastrointestinal

Soft, non-tender, non-distended, positive bowel sounds in the four quadrants, no

rebound, no guarding, no organomegaly. LBM 01/16/18.

Breast

Deferred

Genitourinary

No bladder distention or CVA tenderness. LMP 12/25/17.

Musculoskeletal

Full ROM seen in all 4 extremities; Good muscle tone and correct spinal posture.

Neurological

AAO x 4. Intact CN I-XII. No neuro focal deficits appreciated

Psychiatric

Normal mood and affect. Able to maintain engagement throughout exam. No s/s of depression or anxiety

Lab Tests

None

Special Tests

None

 Diagnosis

 Differential Diagnoses

1- Dry eye syndrome of unspecified lacrimal gland- H04.129: Is a multifactorial disorder characterized by abnormalities in the tear film and ocular surface leading to symptoms of irritation, discomfort, and visual disturbance (Buttaro et al, 2013)

2- Retained foreign body in unspecified eye, unspecified eyelid- H02-819: The most common symptom of foreign body is severe eye pain in the affected eye. Some patients may present with a foreign body sensation instead of severe pain. Other symptoms include blurred vision, redness, tearing, light sensitivity, eyelid swelling, and blepharospasm (Buttaro et al, 2013)

3- Other conjunctivitis- H10.89: is inflammation of the conjunctiva, the transparent mucosal tissue that lines the eye and inner surface of the eyelids. Commonly referred to as pink eye, conjunctivitis actually consists of many different disorders. Infectious causes include viruses and bacteria. Allergic, atopic and vernal, and toxic conjunctivitides are noninfectious (Buttaro et al, 2013)

Ocular symptoms include acute onset of a red eye with excessive watery discharge. Itching, photophobia, watering, and foreign body sensation can be present. Patients can often recall the precise moment when symptoms began. Classically, it begins in one eye and then involves the fellow eye within days. Approximately half of patients will have bilateral involvement (Buttaro et al, 2013)

Diagnosis

- Other conjunctivitis- H10.89

Plan/Therapeutics

Plan:

- Polymyxin B/trimethoprim ophthalmic 0.5% 1 drop into the affected eye four times daily.

- Cold compresses to be applied to affected eyes 4-6 times per day.

Education:

- Discussed with patient risk and benefits of medication.

-Take medications as prescribed, do not exceed the recommended dosage; do not stop even if symptoms improve.

- Eyes can be clean in the morning from inner to outter canthus using a warm cloth that must not be re-used until washed throughout.

- Patients should avoid touching their eyes, shaking hands with others, sharing towels or bedclothes, and swimming in public pools.

-Patient instructed on the importance of hands washing with antimicrobial soap to avoid the spread of the disease.

- Patient instructed to follow up in a week or contact healthcare provider if symptoms do not improve or continue to worsen.