3 – Eye | CLINIBORG

HISTORY:
provided by patient provided by family member SO/family member present during visit chaperon/MA present during visit interpretation provided by family member/SO interpretation provided by MA complete history unobtainable d/t poor effort/affect complete history unobtainable d/t cognitive changes or lack of knowledge complete history unobtainable d/t language skills

CC:
pain redness burning itching discharge matting eyelid swelling periorbital swelling pain with EOM trauma foreign body sensation decreased vision decreased peripheral vision decreased central vision blurred vision diplopia scotoma photophobia

AFFECTED EYE:
right left both

STATED CAUSE:
unknown trauma chemical exposure welding arc tanning booth/beach foreign body dust metal particle

HPI:
sudden onset gradual onset started just prior to arrival started today started yesterday started days ago started months ago washed eyes at scene/home doing compresses applying ointment sx increasing in severity sx persist sx decreasing in severity

PAST/RECENT HISTORY:

PCP visit ER/UC visit hospitalization travel sick contact new/changed medications antibiotic use injury glaucoma eye surgery connective tissue disease

REVIEW OF SYSTEMS: [+] reported [-] not reported
negative except as stated in HPI
CONSTITUTIONAL:

objective fever subjective fever chills fatigue weight loss
EARS:

pain pressure discharge bleeding wax
ENT:

facial numbness nasal discharge bleeding mouth sores sore throat hoarseness earache
NECK:

pain stiffness swelling swollen glands
CV:

chest pain/pressure SOB palpitations dyspnea orthopnea ankle swelling ankle discoloration varicose veins leg cramps
CHEST/RESPIRATORY:

chest tightness pain w/ breathing rib pain
GI:

poor appetite nausea vomiting generalized abdominal discomfort abdominal pain constipation diarrhea
GU:

dysuria hematuria itching genital lesions
MSK:

neck pain back pain extremity pain generalized joint pain myalgias
NEURO:

dizziness vertigo poor balance abnormality of walk focal weakness blackouts seizures tingling/numbness
PSYCH:

irritability confusion depression anxiety mood swings memory loss insomnia
LYMPH/HEMA:

gland swelling bruising anticoagulation DVT/clotting anemia
ALLERGIES/IMMUNE:

atopy food allergies autoimmune dz h/o cancer
DERM:

dryness pruritus rash hives redness swelling wounds new or suspicious lesions

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Appearance:
well-appearing alert non-toxic normal WOB allows exam poor cooperation with exam crying but consolable ill-appearing tired-looking short of breath diaphoretic drowsy appears impaired slumped

Skin:
warm, dry grossly intact, no rashes no bruises normal turgor dry tattoos body piercings pallor cyanosis poor turgor diaphoresis rash

Ears:
symmetrical & intact auricles bilaterally hearing to conversation intact clear canals without erythema or discharge TMs normal in appearance TM obscured by cerumen TM red mastoid tenderness

Nose:
nares patent bilaterally septum midline mucosa pink & moist mucosal edema clear discharge purulent drainage

Mouth:
moist oral mucosa without lesions upper front teeth non-tender and immobile upper denture lower denture dental decay oral ulcers

Throat:
normal voice patent pharynx w/o swelling or exudates uvula midline hoarseness pharyngeal erythema w/o exudates pharyngeal crowding tonsillar enlargement tonsillar erythema tonsillar exudates tonsillar crypts tonsillar pustules

Neck:
symmetric with free painless ROM no LAD anterior LAD posterior LAD nuchal tenderness

Chest/Lungs:
normal work of breathing, symmetrical chest expansion no retractions clear and equal breath sounds bilaterally respiratory distress breath sounds decreased coughing wheezing crackles poor effort

CV:
regular rhythm no murmurs no ankle edema tachycardia irregular heart rhythm pedal edema

Abdomen:
not examined normal visual inspection, no distension normal active bowel sounds soft non-tender

GU:
not examined no suprapubic tenderness no CVAT bilaterally normal external genitalia

MSK:
no gross deformities, moves all extremities with good ROM for age full weight-bearing normal curvature & ROM spine for age

Neuro:
ambulates w/o limp or alteration in gait balance & coordination grossly intact extremities strong w/o atrophy, tremor or fasciculations normal speech normal concentration and attention memory grossly intact no gross motor deficits sensation symmetrical & grossly intact

Head/Face:
normocephalic, atraumatic symmetrical face CN V intact no facial/temple tenderness no palpable orbital deformity/tenderness periorbital swelling periorbital tenderness

Visual Acuity:
grossly intact with glasses without glasses 20/20

EOM:
intact nystagmus palsy dysconjugate gaze

Pupils:
PERL normal accommodation normal reaction to direct and consensual light dilated constricted anisocoria irregular shape ciliary flush direct photophobia consensual photophobia

Affected Eye - Globus:
non-tender proptosis tender

Affected Eye - Eyelids:
normal inspection everted for exam edema erythema ptosis stye no FB visible FB in sulcus

Affected Eye - Conjunctiva/Sclera:
normal inspection injection epiphora exudate chemosis pterygium subconjunctival hemorrhage no fluorescein uptake fluorescein uptake

Affected Eye - Cornea:
normal inspection smooth no fluorescein uptake fluorescein uptake

Affected Eye - Anterior Chamber:
normal inspection hyphema cloudy

Affected Eye - Fundus:
unable to examine normal abnormal

Unaffected Eye:
normal exam abnormal:

Behavior:
calm, pleasant, respectful cooperative with exam uncooperative with exam guarded anxious fearful suspicious hypervigilant irritable frustrated restless labile sighing crying agitated raising voice defensive argumentative hostile forceful intense euphoric demanding particular medication, test, referral, or accommodation withdrawn indifferent appears to be responding to internal psychotic process

Psychomotor Activity:
no involuntary movements tremor tardive dyskinesia tics bradykinetic fidgeting picking skin twirling hair cracking knuckles threatening posture/movement grimacing, furrowing eyebrows tightening jaw breathing hard shaking extremities clenching fists intense staring standing up and/or pacing opening door to hallway exited exam room during exam

Speech/Vocalization:
normal rate & rhythm clear & coherent slurred monotonous stuttering hypoverbal hyperverbal loud soft slow rapid pressured repetitive questions cursing, swearing criticisms of staff verbal threats

OFFICE DIAGNOSTICS:
none rapid strep NEG

IMAGING:
none X-ray CT facial series orbital series essentially normal no orbital fx staff to notify patient once radiology report becomes available

DX:
conjunctivitis
viral syndrome
eye pain
decreased vision
acute iritis
glaucoma
allergic conjunctivitis
corneal abrasion
corneal ulcer
foreign body
ultraviolet keratitis

A/P:

PLAN OF CARE:
POA risks/benefits/side effects/alternatives discussed with patient/parent/SO, opportunity provided to ask questions verbalized understanding of and agreement with POC, discharge & f/u instructions patient/family did not agree with my POA/recommendations – will seek second opinion/further care elsewhere

PROCEDURE:
none proparacaine applied fluorescein dye applied eye examined no areas of increased uptake of fluorescent stain under cobalt blue corneal FB removal attempted with cotton-tipped swab corneal FB removal attempted with needle/burr scleral FB removal attempted with cotton-tipped swab scleral FB removal attempted with needle/burr eye irrigated with NS no FB material visible EOM intact cornea clear rust ring remaining visual acuity reevaluated post procedure - unchanged

RX:
none paper electronic given to MA to be transmitted to pharmacy

REFERRALS:
none ophthalmology

REVIEWED:
MA notes med list previous visits previous laboratory/diagnostic studies

INSTRUCTED ON:
vital signs/exam findings/recommendations appropriate follow up & possible specialty consult if sx don't improve in 3 days reporting medication side effects immediately laboratory/diagnostic studies

BARRIERS TO CARE:
none identified poor cooperation with exam lack of motivation negative attitude to diagnostic impression & proposed tx incomplete history vague shifting complaints history not supported by objective findings parental anxiety poor compliance with POC multiple comorbidities polypharmacy lack of interest in nonpharmacologic therapies overwhelming focus on Rx drugs intolerance of multiple meds frequent ER/UC visits altered mental status hostile/disruptive behavior active psychiatric diagnosis alcohol or substance use social/cultural barriers victim of abuse tangential thinking perseveration flight of ideas preoccupation with illness catastrophization overgeneralization unrealistic beliefs negativism pessimism blaming others staff splitting delusions paranoid ideation

FOLLOW UP:
RTC as discussed, sooner if condition worsens or new symptoms arise, contact 911/ER if significant increase in s/sx or appearance of new/danger s/sx, PRN 24 hours 48 to 72 hours

DISPOSITION:
home referred to ER for immediate treatment via 911 referred to ER for immediate treatment via private transport declined emergency transfer left facility before being discharged asked to leave clinic

3 – Eye

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