8 Years Old Female Patient SOAP Note

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Patient: 8 years old female, coming for consultation complaining of productive cough, fever, nasal congestion and malaise. on the physical examination, patient with 102 of fever, Breath sounds present with ronchi on both lung bases. Tylenol was given orally, CBC done in office with WBC count of  9000. Rocephin 1mg IM stat

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8 Years Old Female Patient SOAP Note

Soap Note # _2__  

Main Diagnosis: Bacterial Conjunctivitis

Patient initials: M.G.

Age: 7 years old
Race: Hispanic
Gender: Female
Information Source: Mother
Allergies: None reported
Medication History: No current medications
Family History: No significant family history
Past medical History (PMH): No significant past medical history
Immunization status: Up to date
Developmental stage: Age-appropriate
Hospitalization: None
History of mental illness/personality disorders: None
Physical trauma/falls: None
Surgeries: None
Exercise: Active, plays outside daily


Diet: Balanced diet, no restrictions
Social History: Lives with parents, attends school
Last annual physical exam: 6 months ago

SUBJECTIVE

Chief complaint: “My daughter is having some leakage from her left eye and couldn’t opened the other day.”

History of present illness (HPI): M.G. is a 7-year-old female child with a 2-day history of sticky discharge from the left eye and swelling of the same eye. The mother describes it as yellow and thick, and M.G. cannot open her eyes in the morning. She denies any history of recent trauma to the eye, fever, and other systemic complaints. M.G. has never experienced conjunctivitis, and she has no allergies. She has been in close contact with classmates who have developed similar symptoms within the last few days.

 

REVIEW OF SYSTEMS:

CONSTITUTIONAL: Denies fever, chills, or weight loss.

NEUROLOGIC: No headaches, dizziness, or changes in vision.

HEENT: Positive for left eye drainage and swelling. Denies ear pain, sore throat, or nasal congestion.

CARDIOVASCULAR: Denies chest pain or palpitations.

RESPIRATORY: Denies cough, shortness of breath, or wheezing.

GASTROINTESTINAL: Denies nausea, vomiting, diarrhea, or abdominal pain.

GENITOURINARY: No dysuria or frequency.


MUSCULOSKELETAL: No joint pain or swelling.

INTEGUMENTARY: No rashes or itching.

OBJECTIVE

Physical Exam

Vitals Signs: Resp: 19 r.p.m Pulse: 71 b.p.mTemp: 97.8 F Weight: 45 lbs Height: 4 ft BMI: 16.1 (Normal) BP: No taken.

GENERAL APPEARANCE: Alert and well-appearing, no acute distress.

NEUROLOGIC: Alert and oriented, cranial nerves II-XII intact, no focal deficits.

HENT:

  • Head: Normocephalic, atraumatic.
  • Eyes: Left eye with erythema and swelling of the conjunctiva, yellow discharge present. Right eye clear with no discharge. Pupils equal, round, and reactive to light. Extraocular movements intact.
  • Ears: Tympanic membranes clear bilaterally.
  • Nose: Nasal mucosa pink, no discharge.
  • Throat: Oropharynx clear, no erythema or exudates.

CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or gallops.

RESPIRATORY: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi.

GASTROINTESTINAL: Soft, non-tender, no hepatosplenomegaly.

GENITOURINARY: No abnormalities noted.

MUSCULOSKELETAL: Full range of motion, no deformities or tenderness.

SKIN: No rashes or lesions.

 

ASSESSMENT:

Patient is a 7-year-old female child who was brought for consultation by her mother with a 2-day history of sticky discharge from the left eye and swelling of the same eye. The mother describes it as yellow and thick, and M.G. cannot open her eyes in the morning. She denies any history of recent trauma to the eye, fever, and other systemic complaints. M.G. has never experienced conjunctivitis, and she has no allergies. She has been in close contact with classmates who have developed similar symptoms within the last few days. On the physical examination Vital signs within normal limits, there is evidence of Left eye with erythema and swelling of the conjunctiva, yellow discharge present. Right eye clear with no discharge. Pupils equal, round, and reactive to light. Extraocular movements intact. Physical findings were consistent with diagnosis of bacterial conjunctivitis, We ordered a course of antibiotics topical, and provided patient and parent education.

 

Main Diagnosis:

Bacterial Conjunctivitis ICD-10 Code: H10.021: Bacterial conjunctivitis is the inflammation of the conjunctiva, which manifests signs like redness, swelling, and thick pus (Bhat & Jhanji, 2020). The symptoms of sticky, yellow discharge from the left eye, swelling, and redness are typical of bacterial conjunctivitis; however, the lack of fever and recurrence in close contacts indicate bacterial rather than viral or allergic etiology. Conjunctivitis is often transmitted through contact with contaminated hands or objects, which is in line with the recent close contact with symptomatic classmates. Thus, based on the clinical signs and symptoms of the case, the most suitable diagnosis for M.G. is bacterial conjunctivitis.

 

Differential diagnosis

Viral Conjunctivitis ICD-10 Code: B30. 9: Viral conjunctivitis presents similarly to bacterial conjunctivitis with symptoms such as redness, tearing, and eye discharge (Muto et al., 2023). The discharge from viral conjunctivitis is usually watery, unlike bacterial conjunctivitis. M.G. denies upper respiratory infection symptoms like cough and nasal congestion. Viral conjunctivitis spreads easily through contact with contaminated surfaces or respiratory droplets. Given M.G.’s recent exposure to classmates with comparable symptoms, viral conjunctivitis is a differential diagnosis, but less likely than bacterial due to discharge and absence of systemic symptoms.

 

Allergic Conjunctivitis ICD-10 Code: H10. 45: Allergic conjunctivitis presents with symptoms of itching, tearing, and bilateral eye involvement (Tariq, 2024). Allergic conjunctivitis, which develops seasonally or in response to allergens like pollen or pet dander, has clear, watery discharge and unilateral involvement, unlike bacterial conjunctivitis. M.G. does not have itching or bilateral eye involvement, reducing the risk of allergic conjunctivitis. However, it is worth considering, especially if there is a history of allergies or allergen exposure.

 

PLAN

Diagnostic test ordered Labs and Diagnostic Test to be ordered (if applicable): None necessary at this time, clinical diagnosis based on history and physical exam

Pharmacological treatment:

  • Polymyxin B/trimethoprim eye drops: Instill 1-2 drops in the affected eye every 4 hours while awake for seven days. This combination antibiotic acts on the various types of bacteria known to cause conjunctivitis.
  • Erythromycin ophthalmic ointment: Use a 1 cm ribbon of ointment, which should be instilled inside the lower eyelid of the affected eye six times daily for seven days (Mayo Clinic, 2024). This antibiotic also targets regular bacterial pathogens, and it can be easily administered to young children.

Non-pharmacological measures:

  • Warm compresses: Wash the affected eye with a warm and wet cotton ball 3-4 times daily, for 5-10 minutes each time. This aids in easing and washing the discharge and affords relief.
  • Good hand hygiene: Promote proper hand washing with soap and clean water to reduce the transmission of the infection.
  • Avoid touching/rubbing eyes: Tell M.G. not to touch or rub her eyes so the irritation will not spread further.
  • Keep the eye clean: Wipe the affected eye with a clean cloth and warm water to wash away the discharge.

Education:

Education:

  • Advise the patient to refrain from touching or rubbing the eyes further to minimize the spread of the infection.
  • Stress the need to fully comply with the usage of prescribed antibiotics even during times of reduced symptoms to eliminate all the bacteria.
  • Advise the patient to wash hands more often and vigorously, using soap and clean water, to avoid contracting the flu.
  • Explain the need for M.G patient to be out of school for at least 24 hours after starting the antibiotics to avoid passing the infection to others.
  • Advised to mother of M.G that patient should return to the clinic immediately if she experiences any new symptoms, including changes in vision, severe pain, and systemic symptoms like fever.

 

Referral/Follow up:

A check-up should be done in 7 days to assess the effectiveness of the treatment administered. In the absence of improvement or if the patient’s condition deteriorates, it might be necessary to see an ophthalmologist specialist.

References

Bhat, A., & Jhanji, V. (2020). Bacterial Conjunctivitis. Infections of the Cornea and Conjunctiva, 1–16. https://doi.org/10.1007/978-981-15-8811-2_1

Mayo Clinic. (2024, February 1). Erythromycin (Ophthalmic Route) Description and Brand Names – Mayo Clinic. Www.mayoclinic.org. https://www.mayoclinic.org/drugs-supplements/erythromycin-ophthalmic-route/description/drg-20068673#:~

Muto, T., Imaizumi, S., & Kamoi, K. (2023). Viral Conjunctivitis. Viruses, 15(3), 676. https://doi.org/10.3390/v15030676

Tariq, F. (2024). Allergic Conjunctivitis: Review of Current Types, Treatments, and Trends. Life, 14(6), 650. https://doi.org/10.3390/life14060650

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