DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: Right eye irritation.
HISTORY OF PRESENT ILLNESS: The patient states that she developed itching and redness in her right eye approximately two days ago. It became acutely worse in the last 24 hours. It is notably irritating and the redness seems to be worsening. The patient has taken gentamicin as she has had infectious conjunctivitis in the past. The patient started taking this again yesterday.
PAST MEDICAL HISTORY: Conjunctivitis in the past. Otherwise, negative.
ALLERGIES: Tetracycline.
MEDICATIONS: Gentamicin eye drops as stated.
SOCIAL HISTORY: No alcohol, tobacco or illicit drug use.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: As mentioned. Otherwise, negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 138/88, pulse 82, respirations 18, temperature 98.6, and pulse ox 99% on room air.
GENERAL: The patient is awake, alert and oriented, in no acute distress.
HEENT: Normocephalic and atraumatic. Eyes: Right eye is notably red within the sclera. Conjunctivae are erythematous and boggy. Otoscopic exam is normal. Fluorescein stain does not reveal any corneal abrasions.
NECK: No lymphadenopathy, no carotid bruits. Neck veins are flat.
LUNGS: Good breath sounds bilaterally with no rales, rhonchi or wheezes.
HEART: Regular rate and rhythm with no murmurs, rubs or gallops.
ABDOMEN: Soft, nontender, nondistended. Good bowel sounds with no organomegaly.
EXTREMITIES: No clubbing, cyanosis or edema.
EMERGENCY DEPARTMENT COURSE: The patient was seen and evaluated in the emergency room by Dr. Jane Doe and myself for evaluation of right eye irritation, redness and itchiness. There was a recent bout of pink eye at her workplace, in which several co-workers came down with infectious conjunctivitis. In fact, the patient has had this in the past and was given gentamicin eye drops. The fluorescein stain did not reveal any corneal abrasions. Due to her acutely inflamed conjunctivae, she was diagnosed with right conjunctivitis.
DISCHARGE DIAGNOSIS: Right conjunctivitis.
PLAN:
1. The patient should continue the gentamicin. We have asked her several times if she has enough left. She states that she does have a whole bottle and that she would rather take this than a new prescription. This is certainly acceptable in the face of conjunctivitis.
2. The patient should avoid being in contact with anyone else who has conjunctivitis.
3. The patient should definitely refrain from returning to work.
DISPOSITION: The patient was discharged to home in stable condition.
