H&P #1

Identifying data:

  • Date & Time: February 9, 2023 12:00pm
  • Full name: S. P.
  • Address: ——-
  • Date of birth: –/–/94
  • Location: Jamaica, NY
  • Source of information: Self
  • Reliability: Reliable
  • Source of referral: Self

 

Chief Complaint: “Right eyelid swelling” x 2 days

 

History of Present Illness:

S.P. is a 28yo female complaining of right eyelid swelling x 2 days. Patient states she fell asleep with her makeup on and woke up the next morning with her “eyes glued shut.” States she has noticed yellow discharge from eye throughout the day. Patient admits to a burning and itching sensation. Reports she was rubbing her eyes frequently the night before and swelling and caused swelling to worsen. Patient states she has been applying warm compresses at home every 4 hours. Denies contact lens use, pain with ROM of eyes, vision changes, fever, sore throat, rhinorrhea, nasal congestion, cough.

Patient is sexually active with 1 male partner. Admits to protection use. States she is not concerned for STDs. Denies history of STDs.

 

Past Medical History:

  • No past medical history

Past Surgical History:

  • No past surgical history

Medications:

  • No medications
  • No herbal supplement use

Allergies:

  • No known drug allergies
  • No known food allergies
  • No known environmental allergies

Family History:

  • Mother: Age 56, alive and well, PMHx HTN
  • Father: Age 58, alive and well, no significant PMHx
  • Maternal grandparents: unknown
  • Paternal grandparents: unknown

Social History:

  • Smoking: non-smoker
  • Substance use: denies alcohol or drug use
  • Caffeine: Admits to caffeine use, 1 cup of coffee per day
  • Occupational history: customer service representative
  • Home situation: lives in apartment alone

 

Review of Systems:

  • General: Denies generalized weakness/fatigue, fever, chills, night sweats, weight loss or gain, changes in appetite.
  • Skin, hair, nails: Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, changes in hair distribution.
  • Head: Denies head trauma, vertigo.
  • Eyes: Admits to eyelid swelling and pruritus. Denies contacts/glasses use, visual disturbances, photophobia, lacrimation. Last eye exam about 1 year ago.
  • Ears: Denies deafness, ear pain, discharge, tinnitus.
  • Nose: Denies epistaxis, discharge, congestion
  • Mouth/throat: Denies sore throat, voice changes, bleeding gums.
  • Neck: Denies localized swelling/lumps, stiffness/decreased ROM
  • Breast: Denies lumps, nipple discharge, pain.
  • Pulmonary: Denies cough, dyspnea, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, wheezing, cyanosis, hemoptysis.
  • Cardiovascular: Denies chest pain, edema/swelling of ankles or feet, hx of HTN, palpitations, irregular heartbeat, syncope, known heart murmur.
  • Gastrointestinal: Denies change in appetite, intolerance to specific foods, abdominal pain nausea, vomiting, dysphagia, pyrosis, unusual flatulence or eructations, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, or blood in stool.
  • Genitourinary: Denies urinary frequency, urinary urgency, nocturia, oliguria, polyuria, dysuria, incontinence, flank pain, hematuria, history of hernias.
  • Menstrual/Obstetrical: G0, P(T0 P0 A0 L0), menarche age 16, LMP 2/05/23, regular menstrual cycles every 28-30 days. Denies hot flashes, vaginal discharge. Last pap smear exam 1/12/23, normal.
  • Sexual History: Admits to currently being sexually active with 1 male partner. Admits to condom use. Denies history of STIs.
  • Musculoskeletal: Denies arthritis, muscle pain, deformity or swelling, redness.
  • Nervous system: Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition/mental status/memory.
  • Peripheral vascular: Denies intermittent claudication, varicose veins, coldness or trophic changes, color changes, peripheral edema.
  • Hematologic: Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions, history of DVT/PE.
  • Endocrine: Denies polydipsia, polyphagia, heat or cold intolerance, excessive sweating, goiter, hirsutism.
  • Psychiatric: Denies depression/sadness, anxiety, OCD, or ever seeing a mental health professional.

 

Physical Exam:

Vitals:

  • BP: 108/67 (seated, right arm)
  • HR: 73 BPM (regular)
  • RR: 16/min (unlabored)
  • T: 98.9 F (oral)
  • O2: 99% (room air)
  • Height: 65in Weight: 136lbs     BMI: 22.6

General: AAO x 3, appears in no acute distress, well groomed, appears stated age

Skin: Warm & moist; good turgor; non-icteric; no rashes or lesions noted

Head: Normocephalic, atraumatic, non-tender to palpation throughout

Eyes: Right eye – Moderate swelling of upper eyelid, non-tender to palpation. + Conjunctival Injection. Yellow mucopurulent discharge noted at medial corner of eye. PERRLA. EOMs intact with no nystagmus. Visual fields full OU. No proptosis or chemosis.

Left eye – No swelling present. PERRLA. EOMs intact with no nystagmus. Visual fields full OU.

Visual acuity: uncorrected – 20/20 OS, 20/20 OD, 20/20 OU

Ears: TM pearly grey and intact with light reflect in good position AU. No tenderness, discharge or foreign bodies.

Nose: Symmetrical. Nares patent bilaterally, nasal mucosa pink and well hydrated.

Sinus: Non-tender to palpation.

Mouth/pharynx: Mucosa pink and well hydrated. Pharynx non-erythematous. No exudates or lesions visualized. Uvula midline.

Neck: Trachea midline. Supple and non-tender to palpation. No cervical adenopathy noted.

Cardiac: Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmur.

Chest: Symmetrical, no deformities. Respirations unlabored, no accessory muscle use.

Lungs: Clear to auscultation bilaterally.

Abdomen: Abdomen flat and symmetric, no scars, striae or pulsations noted. Bowel sounds normoactive in all four quadrants. Tympanic throughout, nontender, no guarding or rebound noted. Negative CVA tenderness.

Nervous system: Cranial nerves I-XII intact.

Peripheral vascular: Pulses 2+ bilaterally in upper and lower extremities. No clubbing, cyanosis or edema noted.

Musculoskeletal: FROM (full range of motion) of all upper and lower extremities bilaterally. Non tender to palpation.

Female genitalia: exam not performed.

Rectal: exam not performed.

 

Differential Diagnosis:

  1. Hordeolum
  2. Chalazion
  3. Conjunctivitis – bacterial vs. allergic vs. viral
  4. Blepharitis
  5. Allergic reaction
  6. Insect bite
  7. Cellulitis – orbital vs preseptal

 

Assessment:

S. P. is a 28yo female with no significant PMHx complaining of right eyelid swelling x 2 days. On exam, there is moderate swelling to right upper lid, conjunctival injection and mucopurulent discharge at medial corner. Visual acuity uncorrected reveals 20/20 OD, 20/20 OS, 20/20 OU. Symptoms and signs are consistent with bacterial conjunctivitis.

 

Plan:

  1. Prescribe: erythromycin ophthalmic ointment; Instill 1 cm ribbon into affected eye(s) up to 6 times daily
  2. Care:
    1. Avoid rubbing or touching your eyes
    2. Wash hands with soap and water often
    3. Dispose of all eye makeup used while infected
    4. Wash all sheets, pillow cases, etc used while infected
    5. Clean any discharge with fresh cotton ball or clean wash cloth then dispose or wash thoroughly
    6. Apply warm compresses to help with symptoms
  3. If symptoms do not improve in 2-3 days with proper antibiotic use, please return.
  4. ER precautions: patient advised if they develop severe eye pain, severe headache, nausea, vomiting, visual disturbances to please proceed directly to ER.
  5. Prevention:
    1. Remove all makeup properly before going to sleep
    2. Do not share eye make-up, pillows, towels, etc
    3. Avoid touching eyes
    4. Wash hands thoroughly and often with soap and water