Severity of The Infection Essay Discussion Paper

Subjective:

Chief complain: “eye pain”

PMH: None.

Allergies: None.

HPI: 4-year-old male accompanied by his mother presented to the emergency department with a four-day history of right eye redness discharge and pain. Today the left eye was noted to be reddened as well. His mother notes that his right eye is closed shut in the mornings and requires cleaning throughout the day. The discharge is green and sticky. Mild itching. He denies any pain or visual changes to the eyes. No nausea, vomiting or diarrhea noted. Denies fevers and trauma to the eye. He eats and drinks well. No allergies to pets or seasonal allergies. No respiratory symptoms. Denies any sick contact. Attends daycare daily. No recent antibiotic use. Immunizations are up to date.  Severity of The Infection Essay Discussion Paper

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Objective:

Vital signs : Bp 104/56, HR 98, temperature 36.4, RR 22, Spo2 100 % on R/A

General: appears well, alert, and oriented, coherent, interactive with mom and dad and walking around in emerge. Normal behavior as per parents.

Skin: warm, pink, and dry. No lesions, no nevi

Neck: supple and symmetric, no lymphadenopathy, thyroid not palpable, no masses, lumps

Lungs: O/A clear bilat

Cardiovascular: S1 and S2 normal with no murmur.

Abdomen: soft and nontender. Bowel sounds are present to all 4 quadrants.

Eyes: Right eye sclera Is pink and intact, erythema to the conjunctiva and large amount of green and yellow purulent discharge noted. No lesions or edema. The left eye sclera is slightly pink and intact with no discharge. Both lashes span outwards and evenly distributed. No nodules. Extraocular movement is intact, and eyes move parallel and symmetric. No nystagmus. Pupils equal round and reactive to light at 2 mm. VA :20/20  Severity of The Infection Essay Discussion Paper

Thorax: posterior pharynx Rise and falls symmetrically, tonsils 1+ with no exudate, uvula and tongue are midline and intact.

Nose: No sinus tenderness.

Lymphatics: No lymphadenopathy.

Assessment:

4-year-old male with a four-day history of purulent discharge and redness to the right eye and now redness to the left eye. He does not have any respiratory symptoms or any known allergies. Based on current symptoms this appears to be bacterial conjunctiva. Differential diagnosis includes viral, allergic conjunctiva or hyper acute bacterial conjunctiva. Severity of The Infection Essay Discussion Paper

Plan:

Treatment- often self-limiting, however due to the severity of the infection it would be reasonable to prescribe erythromycin 0.5 % ointment 1-inch QID x 7 days. To treat S.aureus, S.pneumoniae and H. influenzae and M.catarrhalis.

School – Bacterial and viral conjunctivitis are both highly contagious and spread by direct contact with secretions or contact with contaminated objects. Infected individuals should not share handkerchiefs, tissues, towels, cosmetics, linens, or eating utensils. The safest approach to prevent spreading to others is to stay home until there is no longer any discharge, but this is not feasible for most students and for those who work outside the home. Most daycare centers and schools require that students receive 24 hours of topical therapy before returning to school.  Severity of The Infection Essay Discussion Paper

Hygiene – Proper hand and eye hygiene. Cleanse affected eyes by wiping from the inner canthus outward using a single tissue or cotton ball. Clean eyelashes several times a day with weak solution of no tears baby shampoo and water. Cold compresses to comfort, 10 to 15 minutes on then off.

Significant improvements should be noted two to five days after the start of treatment.

Return to the emergency department for fever, visual changes and lack of improvement after 2 days.

NUR 638 SOAP NOTE GRADING RUBRIC

A soap note that is not referenced to a student’s elog will NOT be accepted

Student Name: ____________________________________ Elog Reference: ______________________

Soap #: _________________________ Diagnosis: _________________________________

254033_order file_SOAP-NOTE-2_64f59958a27f2 (2)