Nurse Practitioner SOAP Notes

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 SUBJECTIVE DATA:

            Chief Complaint (CC):Conjuctivitis (pink eye)

History of Present Illness (HPI):

Onset The father of an 8 year old male received a call from the school nurse that the patient had a pink eye.
Location Eyes
Duration Itchy eyes since morning hours
Characteristics Itchy eyes, redness, scant watery discharge, and negative for pain.
Aggravating Factors Foreign objects in the eyes, wheezing, and shortness of breath.
Relieving Factors No family history of allergies or asthma, safe environment at home, gets adequate diet and sleep.
Treatments/Therapies Use of medications and patient education

 

Medications: Albuterol inhaler to control the mild intermittent asthma (Proventil HFA-90mcg/actuation – 2 puffs every 4-6 hours PRN for asthma, use with spacer)

Loratidine- Claritin (10 mg for allergies)

Allergies: The father thinks that the boy might have allergies but has never been clinically diagnosed. He reports that the patient has watery eyes, nasal congestion, and coughs regularly during fall and spring seasons.

Past Medical History (PMH): mild intermittent asthma but was controlled with the occasional use of albuterol inhaler. Has had itching eyes, running nose, and allergic conjunctivitis a few months ago and treated with olopatadine.

Past Surgical History (PSH): N/A

OB/GYN History: (if applicable) N/A

Personal/Social History: Lives with parents, sister and the younger brother. There are no pets at home, and the father reported of a safe environment, adequate diet and sleep. The boy performs well in school.

Immunizations: Flu short for the period

Family History: No likelihood of a history of allergies or asthma.

Review of Systems:

General: Temperature-98.8 F, BMI-14.76, HR-82, Wt-48 lbs

Skin: Negative for rashes

HEENT: Mouth and Throat had moist mucous membranes, no tonsillar exudate, oropharynx is clear, and the pharynx is normal.

Neck: Supple and no rigidity

Eyes: positive for redness and itching bilaterally. Negative for pain, loss of visual acuity and photophobia

Breasts: N/A

Respiratory: No respiratory distress, and no wheezes

Cardiovascular: Regular rhythm, S1, and S2 normal.

Lungs: Negative for wheezing, breath shortness is evident, and has increased work of breathing.

Neurological: Is alert and oriented *3. The CN II-XII is intact.

Endocrine: Normal

OBJECTIVE DATA:

Vital Signs:  HR 82 RR 16 Temperature 98.8 BMI 14.76

(Pediatric) BP % below the 90th

General: Well nourished, active, and cooperative with no acute distress

SKIN: Warm, capillary refill takes less than 3 seconds, and no rash noted. Has no jaundice and shows dryness on the elbows and knees

HEENT: Mouth and Throat had moist mucous membranes, no tonsillar exudate, oropharynx is clear, and the pharynx is normal.

Eyes: Conjunctiva red bilaterally. Has diffuse redness of the palpebral conjunctiva; Has scant watery discharge with pruritis, the pupils are equal, round, and reactive to light. Eyelids have no edema, and the near and distance vision for both eyes is 20/20. The fundoscopic exam is normal, intact vessels, and the optic disc has clear margins.

Neck: Supple and not rigid

Abdomen: soft, non-tender, non-distended. No guarding and bowel sounds in all the four quadrants.

Musculoskeletal: 5/5 strength and ROM in all extremities

Neurological: Is alert and oriented *3. The CN II-XII is intact

Cardiovascular: Regular rhythm, S1, and S2 normal.

Pulmonary: effort normal and breath sounds normal. Normal air entry and respiratory distress

ASSESSMENT:

Diagnosis Positives Negatives Rationale & Reference
Allergic conjunctivitis Positive for the child   Characterized by pruritis, redness and thin, watery discharge (Crounau, Kankanala & Mauger, 2010).
Bacterial conjunctivitis   Negative for the child Eliminated by the absence of thick purulent discharge, fever, vesicular symptoms or unilateral eye redness (Crounau, Kankanala & Mauger, 2010).
Viral conjunctivitis   Negative for the child Eliminated by the absence of thick purulent discharge, fever, vesicular symptoms or unilateral eye redness (Crounau, Kankanala & Mauger, 2010).

 

Lab/Imaging (Results) Patient results Rationale
Thorough eye examination and patient history pruritis, redness and thin, watery discharge, No previous cases of the condition High likelihood of having allergic conjunctivitis due to the positive results for pruritis, redness and thin, watery discharge.

 

Holistic Care

Chronic Condition Status Plan
Allergic conjunctivitis Under treatment after diagnosis medication and use of antihistamine drops

 

Lab/Imaging (Results) Patient results Rationale
eye examination pruritis, redness and thin, watery discharge Effective method in diagnosis of the underlying health condition

 

PLAN:

Condition Pharmacological Nonpharmacological

Alternative Treatments

Test Follow up

Referral

Rationale
Allergic conjunctivit-is Olopatidine (Patanol) 0.1% ophthalmic solution. Place 1 drop into both eyes 2 (two) times daily for 14 days. Patient education- not to rub the eyes because it can cause mechanical mast cell degranulation and worsening of symptoms. Apply cool compress if itching persists. Avoid allergens. Eye examinati-on If there is no improvement after 24 hours of the ophthalmic solution or parental concern for worsening To check the progress of the treatment plan and also likelihood of side effects.
           

 

Health Promotion: Education about the likely causes of allergic conjunctivitis and also the need to sensitize the community about the disorder affecting children.

Disease Prevention: Important to check the visual acuity to assess the changes in vision. If there is a loss of vision, it is necessary to seek clinical assistance.

REFLECTION: I realized that many parents have limited time to assess the health of their children. It was shocking to identify that the father was called by the school nurse to inform him of his child’s illness despite him leaving home in the morning with itchy eyes. It was necessary to have a thorough patient history and eye examination that provides the clues to the etiology of the red eye. I could examine the patient further using a detailed patient history and careful eye examination that helps to develop a suitable treatment plan.

References

Azari, A. A., & Barney, N. P. (2013) Conjunctivitis: a systematic review of diagnosis and             treatment. Jama, 310(16), 1721-1730.

Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., & Blosser, C. G. (2013) Pediatric primary             care (5th ed.). Philadelphia, PA: Elsevier.

Crounau H, Kankanala RR, Mauger T. (2010) Diagnosis and management of red eye in    primary care. Am Fam Physician. 2010; 81:137-44

Teoh, D. L., & Reynolds, S. (2013). Diagnosis and management of pediatric conjunctivitis:           Pediatric emergency care, 19(1), 48-55.



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