S.O.A.P.

Note

A 42-year-old male presents with a right eye that has been irritated for one day. He
complains of eye redness and constant tearing. He wears contacts and felt like he got
something in it yesterday when he was doing yard work.

Chief Complaint
Right eye redness and constant tearing

History of Present Illness

A 42-year-old male presents with a right eye that has been irritated for one day. He
complains of eye redness and constant tearing. He wears contacts and felt like he got
something in it yesterday when he was doing yard work. He removed his contacts and
was rubbing his eye in the morning during his shower trying to rinse his eyes, but it
didn’t help his eye discomfort. He stated that in the morning he also noticed more
redness, mild swelling and tearing in his right eye. He denies any itching. Eye pain
present, describes as “moderate scratching pain” 4/10, which started today in the
morning after awakening from sleep with uncomfortable sensitivity to light in his right
eye. He states that pain is more intense with opening and keeping the eye open, he has
inability to keep open his right eye. He stated that light makes it more painful, tearful
and describes as “constantly crying” with his right eye. His eye pain and discomfort
improved when he keeps his eye closed, 2/10, but still has some sensation that
something is in his eye. He denies any injury and was wearing protective clear-color
garden glasses yesterday during his yard work. He denies using any “toxic chemical
spray” during his gardening. He states that he has history of seasonal allergies and
usually takes Zyrtec over the counter, previously he usually had nasal congestion from
his allergies and didn’t have any eye tearing before. He states that for years he was
wearing glasses for his vision and switched to soft contacts just a few months ago. The
night before he was working in the yard, he switched his contacts for a new pair and
didn’t have any pain, tearing or irritation. He usually changes his contacts once a week
and doesn’t remove them during the night. For the last two weeks he didn’t use any
artificial tear drops or any other eye drops, he has not been cleaning and soaking his
contact lenses daily. He denies any severe or sudden vision loss or any vision changes
such as blurriness, flashing lights or dark spots. He denies any problems with the right
eye previously, including episodes of eye tearing, or any symptoms of dry eyes. Denies
recent sore throat or runny nose, congestion, headache, fatigue, aching joints. His last
complete eye exam was with an opthamologist 2 months ago. He denies any history of
eye surgeries and any recent changes in his medications.
Past Medical History
Past medical history: Hypertension, Hyperlipidemia
Past surgical history: Appendectomy 2005
Patient has not received his flu shot in two years and does not qualify at this time for a
pneumonia vaccine. Patient received all of his childhood immunizations. Tetanus
booster was received within the past year. Patient does not have any known drug
allergies. Has seasonal allergies.
Patient currently takes:
Atorvastatin 20mg, PO, 1 tab ,QD; Lisinopril 10mg, 1tab, PO, QD;

Family History
Mother had hyperlipidemia, high blood pressure, died of a heart attack at 60.
Father had cardiac disease, died of a heart attack at the age of 63
Brother has hyperlipidemia, hypertension, had his first heart attack at 49.
Sister has hyperlipidemia, blood clots, had a stroke at the age of 50.

Personal/Social History
Educated with Bachelor degree, works at “Enterprise car rental”, married, heterosexual.
Patient is active with his family. Patient never smoked. Patient does not use chew
tobacco; patient is not using illicit drugs. Patient states that he is drinking wine socially
when “out with friends, 2-3 times per month, no more than 3 drinks per time”. Patient
does not exercise regularly. Patient is not currently on any diet.

Review of Systems
 General: - fatigue, - chills, - for low grade fever, - lethargy, - weakness, - night
sweats
 Hair, Skin, & Nails: - hair loss, - rashes or skin lesions, - nail changes
 Head: - headache, - dizziness, - loss of consciousness
 Neck: - pain
 Eyes: + use of contacts, - vision changes, - blurry vision, - double vision, -itching,
+ eye pain, + tearing, refer to present illness
 Ears: - hearing loss, - pain, - tinnitus, - vertigo
 Nose: - loss of smell, - nasal congestion, - nasal drainage, - nasal pain, -
epistaxis
  Mouth & Throat: - pain, - dryness, - hoarseness, - difficulty swallowing
 Cardiovascular: - pain, - palpitations, - irregular heart beat
 Respiratory: -cough, - sputum production, - shortness of breath, - wheezing,
-night sweat
 Breasts: - pain
 Gastrointestinal: - for abdominal pain, - nausea, - vomiting, - diarrhea, -
constipation
 Musculoskeletal: - pain, - dislocations, - injuries
 Peripheral: - pain, - discoloration, - temp change
 Neurological: - loss of consciousness, - numbness, - paralysis, - seizures
 Psychiatric: - for suicidal ideations and self-injury, -depression

Physical Examination
 Vital signs: Temp 98.2 F; HR 63; RR 18; BP 132/65; SPO2 99% on RA; Pain
4/10, scratching, Right eye; Height 5’8”, weight 181lb, BMI 27
 General Appearance: Well-developed and well- nourished Caucasian male.
 HEENT: Head is normocephalic. No scalp, forehead, temporal, or sinus
tenderness. Eyes normal size, symmetrical no flakiness, pupils equal, round,
reactive to light, eyelids without nodules, eyelashes present on both lids without
crust. Visual acuity in the R-eye 20/60 , L-eye 20/50. R-eye appears
erythematous, mild lid margin swelling, conjunctiva is pink, sclera is injected with
no jaundice or venous hemorrhage. Visual acuity is normal but unable to keep
his eye open for full exam, to keep open the eye it appears to be painful, he also
exhibits signs of photosensitivity and excessive lacrimation of clear tearing.
Absence of any foreign body. Upon examination with fluorescence stain and slit-
lamp, I noted a small abrasion to the cornea. Left eye exam is within normal
limits. Ear canals are free of cerumen and opaque colored canal; Tympanic
membranes are pearly gray and without erythema. Hearing grossly intact.
Nasopharynx mucosa is pink and moist without drainage. Posterior oropharynx is
without lesions or exudate. No pain or tenderness within the throat. Gag reflex
intact.
 Neck: Supple, trachea is midline, thyroid is not palpable, no carotid bruits, no
JBD
 Lymph Nodes: No cervical or axillary lymphadenopathy
 Chest: chest wall symmetrical and within normal limits
 Cardiac: Sinus rhythm. S1 and S2 are auscultated with regular sounds. No
murmurs, friction rubs, or abnormal sounds present. Intact distal pulses.
 Abdomen: Soft, normal appearance, moderately obese. Bowel sounds present in
all quadrants.
 Genitourinary: Not examined
 Skin: no rashes, normal texture.
 Musculoskeletal: Normal range of motion, exhibits no deformity
  Neurologic: Cranial nerves I-XII are intact, motor and sensory exams within
normal limits.
 Psychiatric: Mood and verbal responses are appropriate to the clinical situation.

Diagnostic Testing/Findings
Penlight and ophthalmoscope
Fluorescence stain and use of cobalt blue filter

Assessment
 Primary diagnosis: Corneal abrasion. Any patient who complains of severe eye
pain with photophobia and/or foreign body sensation preventing opening of the
eye generally can be presumed to have a corneal epithelial defect. (Jacobs,
2019)
 Differential Diagnosis: Intraocular foreign body, Conjectivitas (cornea
abrasion can get infected), Contact lens wear may lead to a
keratoconjunctivitis or giant cell papillary conjunctivitis secondary to infrequent
lens replacement, prolonged wearing time, poor lens hygiene, allergenic contact
lens solutions, ionic nature or high water content, or poor fit of contact lenses.
(Jacobs, 2019)

Plan/Education
A corneal abrasion can be treated with analgesics and antibiotic prophylaxis:
1. Nonsteroidal anti-inflammatory drugs (NSAIDs) -diclofenac ophthalmic (0.1%) 1
drop into affected eye, QID, for two to three days
2. Antipseudomonal topical antibiotics-Tobramycin 0.3% ophthalmic solution, 1 to 2
drops, four times per day for three to five days

3. Teaching: Medication teaching- Instill medication in the outer aspect of the lower
lid. Avoid wearing contact lenses until the abrasion heals. Do not use eyepatch.
Oral analgesia, over the counter, Ibuprofen 200mg, 1 tab PO, 4-6 hr as needed.
Instruct patient that most simple corneal abrasions will heal in 1 to 2 days, if not
better in 24 to 48 hours follow-up with physician. Patients may find some relief in
keeping the eye shut and wearing sunglasses or staying in low light to avoid light
sensitivity. They should avoid touching or rubbing the eye. Contact lenses may
be worn once cleared by an ophthalmologist or, for simple abrasions, once the
patient has been symptom-free for about 24 hours. Ill-fitting or worn contacts
should be replaced. Patients should never use topical anesthetics at home, as
they impede healing and may lead to other complications. Worsening of pain,
any purulent discharge, changes in vision, or lack of improvement in 24 to 48
hours should prompt the patient to return for repeat evaluation. (Jacobs, 2019)

References:

Jacobs, D., (2019)., Corneal abrasions and corneal foreign bodies:

Management., In J. F. Dashe (Ed.), UpToDate. Retrieved from:
https://www.uptodate.com/contents/corneal-abrasions-and-corneal-foreign-
bodies-management?search=cornia
%20abrasion&source=search_result&selectedTitle=1~122&usage_type=default&
display_rank=1#H14488631

Jacobs, D., (2019)., Conjunctivitis., Management., In J. F. Dashe (Ed.),

UpToDate. Retrieved from: https://www.uptodate.com/contents/conjunctivitis?
search=acute
%20conjunctivitis&source=search_result&selectedTitle=1~150&usage_type=defa
ult&display_rank=1