SOAP Note #2: Bacterial Conjunctivitis

## SOAP Note #2: Bacterial Conjunctivitis

### Patient Information
– **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 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 eye 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

– **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 from the left eye and swelling. The discharge is described as yellow and thick, and M.G. cannot open her eye in the morning. There is no history of recent trauma, fever, or other systemic symptoms. The patient has been in close contact with classmates with similar symptoms. Physical examination shows erythema and swelling of the left conjunctiva with yellow discharge. The right eye is clear. These findings are consistent with bacterial conjunctivitis.

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

**Differential Diagnosis**:
1. **Viral Conjunctivitis (ICD-10 Code: B30.9)**: Viral conjunctivitis presents with redness, tearing, and watery discharge. The absence of systemic symptoms makes this less likely.
2. **Allergic Conjunctivitis (ICD-10 Code: H10.45)**: Allergic conjunctivitis presents with itching, tearing, and often bilateral involvement. M.G. does not have itching or bilateral eye involvement, making this less likely.

### PLAN

**Diagnostic Tests Ordered**:
– None necessary at this time; diagnosis based on history and physical exam.

**Pharmacological Treatment**:
1. **Polymyxin B/trimethoprim eye drops**: Instill 1-2 drops in the affected eye every 4 hours while awake for seven days.
2. **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 a warm, wet cotton ball to the affected eye 3-4 times daily for 5-10 minutes each time.
– **Good Hand Hygiene**: Promote proper hand washing with soap and clean water to reduce transmission.
– **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 to remove discharge.

**Education**:
– Advise against touching or rubbing the eyes to prevent the spread of infection.
– Emphasize the importance of completing the full course of prescribed antibiotics.
– Encourage frequent hand washing with soap and clean water.
– Recommend that M.G. stays out of school for at least 24 hours after starting antibiotics to avoid spreading the infection.
– Instruct the mother to return to the clinic if M.G. experiences new symptoms such as vision changes, severe pain, or fever.

**Referral/Follow-Up**:
– A follow-up appointment in 7 days to assess treatment effectiveness. Referral to an ophthalmologist if no improvement or if the 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. [Mayo Clinic](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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