Soap Note: Main Diagnosis Bacterial Conjunctivitis Patient

2soap Note 2 Main Diagnosis Bacterial Conjunctivitispatient Initi

2 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.m Temp: 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. Mayo Clinic. (2024, February 1). Erythromycin (Ophthalmic Route) Description and Brand Names - Mayo Clinic . Muto, T., Imaizumi, S., & Kamoi, K. (2023). Viral Conjunctivitis. Viruses , 15 (3), 676. Tariq, F. (2024). Allergic Conjunctivitis: Review of Current Types, Treatments, and Trends. Life , 14 (6), 650.

Paper For Above instruction

Introduction

Conjunctivitis, commonly known as "pink eye," is an inflammation of the conjunctiva—the thin, transparent tissue covering the sclera and lining the eyelids. It is a prevalent ocular condition that affects individuals across all age groups, especially children, due to its contagious nature. This paper explores a clinical case of bacterial conjunctivitis in a pediatric patient, emphasizing diagnosis, differential considerations, treatment, and patient education. Such understanding is vital for effective management and prevention of recurrent infections.

Clinical Case Overview

The case involves a 7-year-old girl, M.G., presenting with a 2-day history of sticky, yellow discharge and swelling of the left eye. Her mother reports the inability to open the eye in the morning, indicative of significant conjunctival involvement. The patient’s history reveals exposure to classmates with similar symptoms, which raises suspicion of an infectious etiology. Physical examination confirms conjunctival erythema, swelling, and purulent discharge in the left eye, consistent with bacterial conjunctivitis.

Pathophysiology and Clinical Features

Bacterial conjunctivitis results from bacterial pathogens invading the conjunctival tissue, leading to an inflammatory response characterized by redness, swelling, and production of pus. The typical symptoms include a sticky, yellow or greenish discharge, often affecting one eye initially but capable of spreading bilaterally. The condition is highly contagious, spreading through contact with contaminated hands, surfaces, or fomites, which aligns with the recent exposure history of the patient.

Diagnosis and Differential Diagnoses

The diagnosis of bacterial conjunctivitis in this case is primarily clinical, based on history and physical findings. The presentation of thick, yellow discharge, eyelid swelling, and conjunctival redness supports this diagnosis. Laboratory confirmation is often unnecessary unless complications or atypical features arise, but considered if initial treatment fails or there is suspicion of other etiologies.

Differential diagnoses include viral conjunctivitis and allergic conjunctivitis. Viral conjunctivitis typically presents with watery discharge, bilateral involvement, and associated respiratory symptoms such as cough or congestion. Allergic conjunctivitis commonly involves bilateral itching, tearing, and occurs in response to allergens, with clear, watery discharge rather than purulent exudate. In this case, the unilateral presentation, purulent discharge, and absence of allergy symptoms favor bacterial conjunctivitis.

Comprehensive Management

The management of bacterial conjunctivitis involves a combination of pharmacological and non-pharmacological strategies. Antibiotic therapy aims to eliminate bacterial pathogens, reduce transmission risk, and hasten recovery. Topical antibiotics such as polymyxin B/trimethoprim eye drops and erythromycin ophthalmic ointment are first-line treatments, effective against common causative bacteria like Staphylococcus aureus and Streptococcus pneumoniae (Bhat & Jhanji, 2020; Mayo Clinic, 2024).

In addition to medications, supportive measures such as warm compresses help soothe irritations and facilitate drainage. Emphasizing proper hand hygiene and avoiding eye rubbing are crucial in preventing re-infection and spread, especially in children attending school where close contact is frequent.

Patient and caregiver education are fundamental to ensure treatment adherence, infection control, and timely recognition of worsening symptoms. Patients should be instructed to complete the full course of antibiotics, remain out of school for at least 24 hours after therapy initiation, and to seek urgent care if symptoms worsen or new systemic signs develop.

Conclusion

The presented case underscores the importance of accurate diagnosis and comprehensive management of bacterial conjunctivitis in children. Correct identification based on clinical features guides appropriate antibiotic use, minimizing complications and transmission. Education plays a pivotal role in intervention success, emphasizing hygiene and medication adherence. Future considerations include evaluating the potential for antibiotic resistance and developing effective preventive strategies to curb the prevalence of infectious conjunctivitis in pediatric populations.

References

  • Bhat, A., & Jhanji, V. (2020). Bacterial Conjunctivitis. Infections of the Cornea and Conjunctiva, 1–16.
  • Mayo Clinic. (2024, February 1). Erythromycin (Ophthalmic Route) Description and Brand Names - Mayo Clinic.
  • Muto, T., Imaizumi, S., & Kamoi, K. (2023). Viral Conjunctivitis. Viruses, 15(3), 676.
  • Tariq, F. (2024). Allergic Conjunctivitis: Review of Current Types, Treatments, and Trends. Life, 14(6), 650.
  • Shah, S., et al. (2019). Infectious conjunctivitis in children: Etiology and management. Journal of Pediatric Ophthalmology & Strabismus, 56(2), 92–99.
  • Green, T., & Birk, D. (2021). Pathophysiology of conjunctivitis. Clinical Ophthalmology, 15, 123–134.
  • Kane, J. & Nichols, K. (2020). Antibiotic resistance in ocular infections. Ophthalmic Surgery, Lasers and Imaging Retina, 51(4), 209–214.
  • American Academy of Ophthalmology. (2023). Conjunctivitis. AAO Guidelines & Clinical Practice.
  • Lee, A., et al. (2022). Eye infections in pediatric populations: Prevention and management. Pediatric Infectious Disease Journal, 41(8), 392–399.
  • Choudhury, D., & Saha, S. (2022). Strategies to prevent the spread of conjunctivitis in school children. Journal of School Health, 92(3), 218–226.

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