Identifying Data: 

Full Name: XX

Address: XX

Date of Birth: XX

Date & Time: 01/04/2024 3PM

Location: Nao Medical Hicksville, NY

Religion: Christian

Source of Information: Self and Parents

Reliability: Reliable 

Source of Referral: Self 

Mode of Transportation: Self 

 

Chief Complaint: “I have pink eye” x 1 day 

History of Present Illness: 

An 11 year old male with no PMHx presented to urgent care with left eye redness for one day. The patient explains that he woke up with his eye “glued shut” from yellow, purulent discharge. He endorses itching. He reports that he has not taken any measures to alleviate his symptoms. He states that he has had no sick contacts. He denies fever, chills, foreign body sensation, pain, flashes, floaters, photophobia, and visual changes. 

Past Medical History: 

Present Illnesses: none

Immunizations: Fully up to date

Screening tests & results: None

Childhood illnesses: None 

 

Past Hospitalizations: 

None

Past Surgical History:  

None

Medications: 

None

Allergies: 

No known food allergies

No known drug allergies

 

Family History: 

Mother – alive and well 

Father – alive and well 

Maternal Grandmother – alive and well 

Maternal Grandfather – alive and well 

Paternal Grandmother –  alive and well 

Paternal Grandfather –  alive and well 

 

Social History: 

Mr. JP is a child living in a home with his mother, father, and maternal grandparents. Mr. JP regularly attends school and afterschool activities. 

Habits: Denies smoking. Denies consumption of coffee.

Travel: Denies recent travel  

Diet: Admits to a well balanced diet.

Exercise: Admits to exercise, playing sports after school.

Safety measures: Admits to using seatbelt in moving vehicles. 

 

Review of Systems:

General – Denies weight loss, fever, malaise, weight change, or night sweats.

Skin, hair, nails – Denies discoloration, pruritus, excessive sweating, skin changes, and hair changes.

Head – Denies headache, dizziness, trauma, fainting, and Hx of vertigo.

Eyes – Endorses discharge and itching. Denies diplopia, eye pain, visual changes, and photophobia. Last eye exam: 3 months ago.

Ears – Denies deafness, pain, discharge, tinnitus or use of hearing aids. 

Nose/Sinuses – Denies sinus pressure, epistaxis, nasal congestion, discharge, swelling.  

Mouth/Throat – Denies dysphagia, sore throat, hoarseness, cough. Last dental exam: 2 months ago.

Neck – Denies pain with movement, stiffness, swollen glands and trouble swallowing.  

Breasts – Denies skin changes, lumps, nipple discharge. 

Pulmonary System – Denies cough, SOB, DOE, wheezing, hemoptysis or cyanosis. 

Cardiovascular System – Denies chest pain, palpitations, edema. Last EKG: has never gotten one.

Gastrointestinal System – Denies loss of appetite, changes in stool, abdominal pain, hemorrhoids, constipation, rectal bleeding or diarrhea. 

Genitourinary System – Denies frequency, oliguria, urgency, nocturia, incontinence or flank pain.

Nervous – Denies dizziness, sensory disturbances, paresthesia, or changes in cognition/mental status. 

Musculoskeletal system – Denies swelling/stiffness, joint pain, muscle soreness, reduced mobility. Denies tenderness to palpation and erythema. 

Peripheral vascular system – Denies pins and needles, edema, calf pain, varicosities, cyanosis. 

Hematological System – Denies Hx of DVT/PE, lymph node enlargement, blood transfusions, anemia, clotting.

Endocrine system – Denies diabetes, heat or cold intolerance, excessive hunger/thirst.

Psychiatric – Denies changes in mood, suicidal ideations, irritability, and changes in eating habits.

Physical 

General: Well groomed male child, with proper posture, appearing as his stated age of 11 years, with small build. He appears awake, alert, oriented to person, place, time and situation. He is cooperative and appears to be a reliable source of information. He is in no acute distress.

Vital Signs: 

BP:  Seated – (R) 92/68

R: 19 breaths/min, unlabored 

P: 90 beats/min, regular rate and rhythm 

T: 99.1 F (Tympanic)

O2 Sat: 98%, room air 

Height: 4’2 inches     Weight: 81 lbs      BMI:  22.8

 

Skin, Hair, Nails, Head:

Skin: Warm and moist. No discoloration. Good turgor. No tattoos, no masses, no bruises, no ulcerations. No visible scarring.

Hair: Regular quantity, even distribution. Color is dark brown, and the texture is normal. No visible dandruff or lice.

Nails: No clubbing, pitting, signs of infection. Presence of lunula on all nails. Capillary refill < 2 seconds in upper extremities.

Head: Normocephalic, atraumatic, non-tender to palpation. 

 

Eyes:

Eyes appear symmetrical. Eye lashes are well distributed. No strabismus, lid lag, or ptosis noted. Sclera with mild erythema, cornea clear with no signs of abrasion or nodules. Conjunctiva is inflamed with no foreign bodies. Visual acuity uncorrected 20/20 OS, 20/20 OD, 20/20 OU. Full visual field. PERRLA and EOM intact with no nystagmus. 

 

Ears

Symmetrical and appropriate in size and shape. No lesions/masses/trauma on external ears. Cerumen present bilaterally, with no discharge or foreign bodies in the ear canal. Tympanic membranes appeared intact, pearly gray/white, with a well positioned cone of light and handle of the malleus. No effusions/pus noted. 

 

Nose/Sinus

Nose symmetrical with no evidence of masses/lesions/deformities/trauma/discharge. Mucosa pink and well hydrated. Nares patent bilaterally. Septum appears midline with no perforations/inflammation or deviation. No foreign bodies noted. Frontal and maxillary sinuses are non tender to palpation. 

 

Mouth/Neck/Pharynx

Lips: Pink, moist, no cyanosis, no lesions or edema. 

Buccal Mucosa: Pink, well hydrated, no masses, lesions or ulcerations, or leukoplakia.

Palate: Pink, well hydrated, no lesions, scars or ulcerations present.

Teeth: Normal dentition, no dental caries present, no plaque buildup.

Gingivae: Moist, with no bleeding, ulcerations, hyperplasia, or discoloration. 

Tongue: Pink, well papillated. Symmetrical with normal texture. 

Oropharynx: Well hydrated, no exudates, masses, lesions or foreign bodies. Uvula pink, midline elevation, no lesions or ulcerations. 

Neck: Trachea midline. No masses, lesions, scars or pulsations noted. Non-tender to palpation.

Thyroid: Non-tender, no palpable masses, no enlarged thyroid. Noted symmetrical movement of thyroid when swallowing, visually and upon palpation.  

 

Thorax/Lungs

Clear to auscultation. Chest was symmetrical with no signs of deformities or trauma. Respirations were unlabored and no accessory muscle use was noted. Non tender to palpation throughout.

 

Heart

Regular rate & rhythm. Distinct S1/S2 with no murmurs, splitting, friction rubs, or S3/S4 appreciated. Carotid pulses are 2+ bilaterally, no bruits present. 

Neuro Exam 

Mental Status: A&O x3, cooperative, thoughts & speech coherent.

Cranial Nerves:

II – Visual fields full by confrontation, visual acuity 20/20 OD,OS,OU corrected.

III & IV & VI – Extraocular movements intact, pupils 3 mm OU and reactive to direct &

consensual light & accommodation, no ptosis.

Differential Diagnosis

• Bacterial Conjunctivitis
• Viral Conjunctivitis
• Allergic Conjunctivitis 

Assessment

An 11 year old male with no PMHx presents to the clinic with left eye redness. He denies related symptoms except for itching. Physical exam demonstrates mild erythema of the sclera with inflammation of the conjunctiva and symmetrical, reactive pupils. There are no changes in visual acuity and PERRLA and EOM are intact. Patient has been discharged with Tobramycin 0.3% ophthalmic solution, instructed to put 2 drops into the affected eye every 6 hours for 7 days.

Problem List

• Bacterial Conjunctivitis 

Plan 

• Tobramycin 0.3% ophthalmic solution, 2 drops into the affected eye every 6 hrs for 7 days.
• Recommend warm compresses to alleviate discomfort and help remove crusting.
• Patient education on proper hygiene practices, including hand washing and avoiding touching the eyes.