Nurse Practitioner SOAP Notes
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.