DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: Eye irritation.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old lady who comes to the emergency department complaining of eye irritation. She states that she was in a fight approximately three weeks ago, at which time she was scratched in her left eye. The patient presented to an outside hospital and was seen and evaluated for such. She was noted to have a corneal abrasion. She had followup with an ophthalmologist. She was seen by the ophthalmologist approximately six days ago and stated that everything was fine at that time. However, she woke up the next day, approximately five days ago, with irritation surrounding her left eye. She, therefore, came to the emergency department, was evaluated, and discharged home. She was given an ointment to place around her eye and told to return should she have worsening symptoms.
She states that it has been worsening. She complains of pain and redness surrounding her left eye. She describes the pain as a burning pain. It is approximately 6/10. It does not radiate. Nothing makes it better. Nothing makes it worse. She denies any blurry vision. She denies any other constitutional symptoms. No headache, no photophobia, no nausea, vomiting, fever, or chills. She denies vertigo.
PAST MEDICAL HISTORY: Depression, hypothyroidism, GERD, and fibromyalgia.
PAST SURGICAL HISTORY: Hysterectomy.
MEDICATIONS: Cymbalta, Synthroid, Protonix, Claritin, oxycodone, clindamycin, Benadryl, and bacitracin.
ALLERGIES: Morphine and penicillin.
REVIEW OF SYSTEMS: No fever, chills, sweats. No cough, cold, congestion. No change in vision or hearing. No one-sided numbness, weakness, tingling. No blackouts, no seizures. All other review of systems is negative.
SOCIAL HISTORY: No tobacco, no ethanol, no drugs. She does not work. She lives alone.
PHYSICAL EXAMINATION:
GENERAL: The patient is a well-developed, well-nourished (XX)-year-old Hispanic female who appears her stated age. She is awake, alert, and oriented x4. She was appropriate throughout the examination.
VITAL SIGNS: Blood pressure 138/100 mmHg, pulse 74 beats per minute, respirations 16 breaths per minute, temperature 97.4 degrees, and O2 sat 99% on room air.
HEENT: Pupils equal, round, and reactive to light. The left sclera is mildly injected. There is no purulent drainage noted. Extraocular motions are intact. Oral mucosa is moist and pink with no visible lesions. The patient has poor dentition.
NECK: Supple. No lymphadenopathy, no JVD, no carotid bruit.
HEART: Regular rate and rhythm. No murmurs, rubs or gallops.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft, nontender, nondistended with positive bowel sounds.
EXTREMITIES: Without cyanosis, clubbing or edema. Pulses 3/4 throughout.
SKIN: Warm, dry and intact. She does have erythema surrounding her left eye. It is approximately 4.5-5 cm in diameter. There are no vesicular lesions. There are no purulent lesions.
EMERGENCY DEPARTMENT COURSE AND MEDICAL DECISION MAKING: The patient was evaluated by myself and Dr. John Doe. Visual acuity was tested. The patient was noted to be 20/40 in both of her eyes. Her left cornea was evaluated via fluorescein staining. The patient was noted to have no corneal defects. It was thought that her irritation may be secondary to the ointment that she is placing around her eye and therefore contact dermatitis. She was therefore advised to cease use of that.
The patient was given a prescription for Bactrim and told to return should she have worsening symptoms, severe pain, nausea, vomiting, fever, chills, numbness, tingling, weakness, dizziness, change in vision or other concerns. This does not appear to be a zoster at this point in time, given the fact that she has no vesicular lesions. There are no eschars, and it is a circumorbital lesion and does not appear to be restricted to one dermatome. The patient did understand reasons for which to return to the emergency department. She had no further questions.
ASSESSMENT: A (XX)-year-old Hispanic lady with contact dermatitis.
PLAN:
1. Discharge home.
2. Discontinue antibiotic ointment.
3. Continue clindamycin and Bactrim as prescribed.
