SOAP Note #2: Bacterial Conjunctivitis in a Pediatric Patient

### 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 open it the other day.”

**History of Present Illness (HPI):**
M.G. is a 7-year-old female 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 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.m
– Temp: 97.8 F
– Weight: 45 lbs
– Height: 4 ft
– BMI: 16.1 (Normal)
– BP: Not taken.

**General Appearance:** Alert and well-appearing, no acute distress.

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

**HEENT:**
– **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

M.G. is a 7-year-old female with a 2-day history of sticky discharge and swelling in her left eye. The discharge is yellow and thick, and she cannot open her eye in the morning. No history of trauma, fever, or other systemic complaints. M.G. has been in close contact with classmates who have similar symptoms. Examination reveals left eye erythema, conjunctival swelling, and yellow discharge, consistent with bacterial conjunctivitis.

**Main Diagnosis:** Bacterial Conjunctivitis
– **ICD-10 Code:** H10.021

**Differential Diagnoses:**
1. **Viral Conjunctivitis**
– **ICD-10 Code:** B30.9
– **Rationale:** Presents similarly with redness and discharge but typically watery. Lacks systemic symptoms of viral infection.

2. **Allergic Conjunctivitis**
– **ICD-10 Code:** H10.45
– **Rationale:** Typically involves itching and bilateral eye involvement. M.G. lacks these symptoms and has no history of allergies.

3. **Chemical Conjunctivitis**
– **ICD-10 Code:** H10.221
– **Rationale:** Typically occurs due to exposure to irritants, but there is no history of such exposure in M.G.’s case.

—

### PLAN

**Diagnostic Test Ordered:**
– None necessary at this time; diagnosis based on clinical history and physical examination.

**Pharmacological Treatment:**
– **Polymyxin B/trimethoprim eye drops:** Instill 1-2 drops in the affected eye every 4 hours while awake for seven days.
– **Erythromycin ophthalmic ointment:** Use a 1 cm ribbon of ointment inside the lower eyelid of the affected eye six times daily for seven days.

**Non-Pharmacological Measures:**
– **Warm Compresses:** Apply to the affected eye 3-4 times daily for 5-10 minutes.
– **Good Hand Hygiene:** Encourage frequent hand washing.
– **Avoid Touching/Rubbing Eyes:** Advise M.G. not to touch or rub her eyes.
– **Keep the Eye Clean:** Wipe the affected eye with a clean cloth and warm water.

**Education:**
– **Hygiene:** Emphasize the importance of good hand hygiene to prevent spread.
– **Medication Adherence:** Stress the importance of completing the full course of antibiotics.
– **School Absence:** M.G. should stay out of school for at least 24 hours after starting antibiotics.
– **Follow-Up:** Return to the clinic if new symptoms arise or if there’s no improvement within a week.

**Referral/Follow-Up:**
– **Check-Up:** Schedule a follow-up in 7 days to assess treatment efficacy. Refer to an ophthalmologist if no improvement or condition worsens.

—

References
– Bhat, A., & Jhanji, V. (2020). Bacterial Conjunctivitis. In *Infections of the Cornea and Conjunctiva* (pp. 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

 

^{"Place your order now for a similar assignment and have exceptional work written by our team of experts, guaranteeing you "A" results."}