Demographics:
Name: FP
Age: 34
Ethnicity: Caucasian
Address: Queens
Location: Statcare Astoria
Source: Self
Reliability: Reliable
History:
CC: I have pain in my left eye since last night, and it is watery.
HPI:
Mr. FP is a 34 y/o Caucasian male who complains of pain and watering of his left eye since last night. He states the pain started suddenly after removing his contact lenses and his been constant. He states the pain feels like a burning sensation. He states the pain feels better when his eye is closed. The pain is non-radiating and he rates it as 8/10. He states his vision is slightly blurry due to the tearing, and states his eyelid is a little swollen. He denies discharge from his eye, redness, flashing lights, floaters, light sensitivity, fever, chills, or fatigue.
Great HPI/ROS
Review of Systems:
General: Denies night sweats, changes in appetite, weakness and recent weight gain or loss.
Skin, Hair, Nails: Denies rashes/moles, discoloration, pruritis
Head: Denies headache, vertigo, head trauma, loss of consciousness or coma.
Ears: Denies deafness, tinnitus.
Nose/sinuses: Denies discharge, epistaxis or obstruction.
Mouth and throat: Denies bleeding gums, sore throat, sore tongue, mouth ulcers.
Neck: Denies localized swelling/lumps or stiffness/decreased range of motion.
Breast: Denies lumps, nipple discharge or pain.
Pulmonary System: Denies dyspnea, shortness of breath, cough, wheezing, hemoptysis, cyanosis, orthopnea or PND.
Cardiovascular System: Denies chest pain, palpitations, irregular heartbeat, edema/swelling of ankles or feet, or syncope.
Gastrointestinal System: Denies abdominal pain, diarrhea, constipation, nausea, vomiting or hematochezia.
Genitourinary: Denies nocturia, urgency, oliguria or polyuria.
Musculoskeletal System: Denies muscle/joint pain, deformity or swelling, redness or arthritis.
Peripheral Vascular System: Denies intermittent claudication coldness, varicose veins, peripheral edema or color change.
Hematologic System: denies anemia, easy bruising or bleeding, lymph node enlargement or history of DVT/PE.
Endocrine System: Denies polydipsia, polyphagia, polyuria, heat or cold intolerance, goiter or hirsutism.
Nervous System: Denies seizures, loss of consciousness, sensory disturbances (numbness, paresthesia, dysesthesia, hyperesthesia), ataxia, loss of strength, changes in cognition/mental status/memory or weakness.
Psychiatric: Denies Anxiety, loss of interest in previously enjoyed activities, or depression.
PMHx: none
Past Surgical History: none
Medications: none
Allergies: Peanuts (hives)
Family History: Unknown
Immunizations: up to date with childhood vaccines
Smoking status: never smoked
Alcohol use: none
Illicit drug use: none
Sexual history: Sexually active with one female partner, uses protection.
Vital:
Vitals:
BP: 122/84
Pulse: 64 (regular)
Resp: 16
Temp: 37.1 °C (oral)
SpO2: 99%
Weight: 64 kg
Height: 172 cm
BMI: 21.6 kg/m2
Physical Exam:
General: A&O x3 not in acute distress
Skin: No visible rashes/moles or discoloration
Head: Normocephalic, no tenderness. No lymphadenopathy.
Eyes: Visual acuity uncorrected 20/30 OD, 20/40 OS. Visual fields full to confrontation OU. Mild swelling and erythema of the left upper eyelid. Sclera white OD, mild sclera injection OS. PERRLA OU. Round spot of fluorescein uptake at 12 o’clock OS. No foreign bodies seen.
Ears: No erythema. Tympanic membrane pearly white with cone of light intact 5 o’clock AD and 7 o’clock AS.
Nose: Nares patent, no discharge.
Mouth/throat: Mucous membranes moist. Uvula rises symmetrically with phonation.
Neck: Non-tender. Thyroid not enlarged and no nodules noted.
Chest/lungs: Lat: AP diameter 2:1. Chest rises symmetrically. Breath sounds clear throughout. No adventitious breath sounds.
Heart: Regular rate and rhythm. S1 and S2 present. No murmurs or gallops.
Abdomen: Non-distended, soft
Musculoskeletal: grossly intact.
Assessment/Plan:
Mr. FP is a 34 y/o Caucasian male who complains of pain and watering of his left eye since last night. Exam reveals corneal abrasion left eye.
Plan: Ciprofloxacin 0.3% ophthalmic solution instill 1-2 drops in left eye 4 times a day for 5 days. Patient counselled not to wear contact lenses for the next 5 days. Patient advised to follow up with Ophthalmologist if symptoms persist or worsen.
Great plan
