Soap Note # 3
Date of Exam: 3/6/23
Source of history:
Subjective/ CC: “My left eye lid is swollen”
Source of history: pt is the primary source of information and is a reliable historian
HPI: 28 y/o Hispanic female presents to the office with c/o left eyelid swelling for the past 3 days. Pt states that last night before bed she had taken Benadryl 25 mg, for the swelling. Pt reports this morning the left eye lid swollen worsened, now it is red and draining. Pt reports the drainage as small amount and red tinge color. Pt also states she feel pain. Pain 4/10 on opening of the eye. Pt admits to vision changes. Pt denies exposure to new lotion, detergents, soap. Pt admits to applying lash extension 1wk ago. Pt denies fever or chills.
Past Medical History: Denies
Past Surgical History: Appendectomy (2016)
Immunization: Up to date- Flu vaccine 12/18/22, Covid vac 12/1/22
Family History
Mother – heart disease
Father – anemia
Medication
none
Allergies: none
Social History
Pt is currently attending a 4 yr college, is employed in food service
Substance Use: denies
Current Smoker Packs/day: 0.25
Years: 5
Alcohol: Denies
Review of Systems
HENT: Positive left upper eye lid swelling, redness and drainage. Denies earaches, infection or discharge. Denies nasal discharge or congestion
Respiratory: Denies cough, shortness of breath
Cardiovascular: Denies chest pain, palpitations or chest discomfort
Gastrointestinal: Negative for abdominal pain, nausea and vomiting
Musculoskeletal: Denies joint pain or stiffness
Skin: Positive for color change to left eye lid, redness
Neurological: Denies dizziness or headaches. weakness, paralysis, numbness or loss of sensation
Objective/ Physical Exam
BP 110/68 (sitting) Pulse 92 Temp 97.9 °F (36.6 °C) (Oral) Resp 16 Ht 167.6 cm (66″) 138lb O2 Sat on RA 98% BMI 23.97
Constitutional: Well-appearing, well-nourished, in no apparent distress. Patient ambulating with steady gait
Head: Normocephalic, atraumatic
Eyes: PERRL, EOM intact without pain, conjunctiva and sclera wnl bil
Edema noted to the Left upper eye, erythematous, draining clear mod amount of drainage with mild tenderness. Left conjunctiva clear, vision in both eyes 20/20 chart used. Fields normal by gross confrontation. Corneal light reflexes equal, corneal intact. Cover test negative, no strabismus
ENT: Normal nose; no rhinorrhea; normal pharynx with no tonsillar hypertrophy, no erythema, no exudate, no lymphadenopathy
Neck/Lymph: Supple; non-tender; no cervical lymphadenopathy or tracheal deviation appreciated; full passive ROM without pain
Cardio: Normal S1, S2; no murmurs, rubs, or gallops
Resp: Normal chest excursion with respiration; breath sounds clear and equal bilaterally; no wheezes, rhonchi, or rales
ABD/GI: Soft, non-distended; non-tender; no palpable organomegaly, no pulsatile mass. No guarding, rigidity, or rebound tenderness noted
EXT/MS: Moves all extremities; distal pulses are normal, no pedal edema. 5/5 muscle strength noted B/L of upper and lower extremities
Skin: Erythema noted to the upper left eyelid
Neuro: Alert and oriented x4, no gross deficits, CN II-XII grossly intact, no motor or sensory deficit noted
Psych: Depression scale used, pt answers questions within normal range
Assessment – Most likely diagnosed: Hordeolum-acute inflammatory most commonly infectious process effecting the eyelid usually caused by staphylococcus aureus. A painfull tender, red infection of the inner or outer margin of the eye lid at the inner margin from an obstructed Meibomian gland; at the outer margin from an obstructed eyelash follicle or tear gland.
Differential Diagnosis:
Chalazion- A subacute nontender, usually painless nodule caused by a blocked Meibomian gland. My become acutely inflamed but unlike a stye usually points the inside the lid rather than on the lid margin.
Conjunctivitis – Conjunctivitis injection: diffuse dilatation of conjunctival vessels with redness that tends to be maximal peripherally. Mild discomfort rather than pain. Vision affected except for temporary mild blurring due to discharge. Ocular discharge watery, mucoid or mucopurulent. Pupils not affected and clear.
Plan:
Start Keflex 250mg po x7 days
Patient educated on the recurrent of symptoms if lash extension is not place with caution
Warm compress to eyelid twice a day
Good hand hygiene
Patient educated on medication side effects and should complete antibiotics as ordered
Smoking cessation and community programs available to help. The patient stated she is willing to start the process of quitting
Pt advised to go to ER for worsening symptoms
Referral: Optometrist