H&P
History
Identifying Data:
Full Name: RS
Address: N/A
Date of Birth: N/A
Date & Time: 04/28/23, 10:00 am
Location: QHC
Religion: N/A
Source of Information: Self
Reliability: Reliable
Source of Referral: Self
Mode of Transport: N/A
Chief Complaint: “I’ve had pain and swelling of my eyelid of my right eye” x 3 days.
12 y/o male with history of styes accompanied by father, up to date with immunizations, presents ED for right upper eyelid pain and swelling that started 3 days ago. Pt notes that it has progressively gotten worse over the course of 3 days and has been experiencing pain with blinking. Also admits to tearing and discharge that causes his eyelids to be stuck in the morning. Denies pain with EOM, blurry vision, foreign body sensation, headaches, trauma, fever, chills, nausea, vomiting, diarrhea, nasal congestion, ear pain, sore throat, recent sick contacts, or recent travel.
Initial DDx:
Periorbital Cellulitis – presents with pain, eyelid swelling and erythema; vision and eye movements are normal
Hordeolum – can present with red, swollen, tender area on external or internal surface of eyelid
Blepharitis – inflammation and redness of eyelid margins
Orbital Cellulitis – can present with deep eye pain, orbital edema, proptosis, chemosis pain with EOM, vision changes
Past Medical History:
Childhood Illnesses- N/A
Immunizations – Up to date; flu vaccine yearly
Screening test and results – N/A
Past Surgical History:
No past surgical history.
Denies any blood transfusions.
Medications:
Not on any medications at this time.
Allergies:
NKDA
Family History:
Mother – 40 y/o, alive and well
Dad – 41 y/o, alive and well
Maternal grandparents – diabetes (grandmother), heart disease (grandfather), alive
Paternal grandparents – alive and well
Denies family h/o cancer, asthma, kidney disease.
Social History:
Patient lives with mother and father.
Habits –No history of smoking, alcohol abuse, or history of illicit substances. Denies drinking coffee.
Travel – No recent travel.
Diet – Has a well-balanced diet.
Exercise – Mom states she is pretty active.
Safety measures – Admits to wearing a seatbelt.
Sexual Hx – N/A
Review of Systems:
General –Denies recent weight loss or gain, fever or chills, night sweats, loss of appetite or generalized weakness/fatigue.
Skin, hair, nails – Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus or changes in hair distribution.
Head – Denies headache or head trauma.
Eyes – Admits to eyelid swelling. Denies lacrimation, pruritus, visual disturbances. Does not wear glasses.
Ears – Denies deafness, pain, discharge, tinnitus or use of hearing aids.
Nose/sinuses –Denies discharge, epistaxis, or nasal polyps.
Neck – Denies localized swelling/lumps or stiffness/decreased range of motion
Breast – Denies lumps, nipple discharge, or pain.
Mouth/throat – Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes or use dentures.
Pulmonary system –Denies dyspnea on exertion. Denies wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).
Cardiovascular system –Denies irregular heartbeat, chest pain, edema/swelling of ankles or feet, syncope or known heart murmur.
Gastrointestinal system – Usually has regular bowel movements daily. Denies nausea, diarrhea and abdominal pain. Denies vomiting, intolerance to specific foods, dysphagia, pyrosis, unusual flatulence or eructations, jaundice, hemorrhoids, or constipation.
Genitourinary system – Denies dysuria and blood in urine. Denies nocturia, urinary frequency, urgency, oliguria, polyuria, incontinence, or flank pain.
Menstrual/Obstetrical – N/A
Musculoskeletal system – Denies muscle/joint pain from arthritis. Denies deformity or swelling, or redness.
Nervous – Denies loss of strength or weakness. Denies seizures, headache, ataxia, change in cognition.
Peripheral vascular system – Denies peripheral edema, intermittent claudication, coldness or trophic changes, varicose veins, or color changes.
Hematological system – Denies anemia, easy bruising or bleeding, lymph node enlargement, or history of DVT/PE. Denies blood transfusion.
Endocrine system – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter
Psychiatric – Denies depression/sadness, anxiety, OCD or ever seeing a mental health professional.
Physical
General: Male appears clean & casually-groomed, alert & active. Also has good posture and well-developed. Does not appear to be acute distress.
Vital Signs: BP: (R) 104/60 (sitting) P: 66 beats/min, regular
(L) 102/60 (sitting)
R: 18 breaths/min, unlabored
O2 Sat: 100 % on room air
T: 36.5 degrees C (oral)
Weight: 30.8 kg
Head, Skin, & Nails
Hair: Average quantity and distribution. Black color. Straight texture. No evidence of lice or seborrheic dermatitis.
Skin: Warm and moist, smooth texture, good turgor.
Nails: No clubbing, capillary refill <2 seconds in upper and lower extremities
Head: Normocephalic, atraumatic, non-tender to palpation throughout.
Eye Exam
Eyes – Right upper eyelid swelling with possible chalazion on right outer upper eyelid with mild erythema.Discharge present. No induration or pain with EOM. Not warm to touch. No strabismus, exophthalmos, or ptosis. Sclera white, cornea clear, conjunctiva pink. Visual acuity uncorrected – 20/0 OS, 20/20 OD, 20/20 OU. Visual fields full OU. PERRLA, EOMs intact with no nystagmus.
Fundoscopy – Red reflex intact OU. Cup to disk ratio< 0.5 OU. No AV nicking, hemorrhages, exudates or neovascularization OU.
Ear Exam
Symmetrical and appropriate in size. No lesions/masses/trauma on external ears. No discharge/foreign bodies in external auditory canals AU. TM’s pearly white/infarct with light reflex in good position AU. Auditory acuity intact to whispered voice AU. Weber midlines/Rhinne reveals AC>BC AU.
Nose & Sinuses Exam
Nose – Symmetrical/no masses/lesions/deformities/trauma/discharge. Nares patent bilaterally/nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions/deformities/injection/perforation. No foreign bodies.
Sinuses – Non-tender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses.
Mouth & Pharynx
Lips – Pink, moist; no cyanosis or lesions. Non-tender to palpation.
Mucosa – Pink ; well hydrated. No masses; lesions noted. Non-tender to palpation. No leukoplakia.
Palate – Pink; well hydrated. Palate intact with no lesions; masses; scars. Non-tender to
Palpation; continuity intact.
Teeth – Good dentition / no obvious dental caries noted.
Gingivae – Pink; moist. No hyperplasia; masses; lesions; erythema or discharge. Non-tender to palpation.
Tongue – Pink; well papillated; no masses, lesions or deviation. Non-tender to palpation.
Oropharynx – Well hydrated; no injection; exudate; masses; lesions; foreign bodies.
Tonsils present with no injection or exudate. Uvula pink, no edema, lesions
Neck Exam
Neck– Trachea midline. No masses; lesions; scars; pulsations noted. Supple; non-tender to
palpation. FROM; no stridor noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally, no cervical adenopathy noted.
Thyroid – Non-tender; no palpable masses; no thyromegaly; no bruits noted.
Thorax & Lungs:
Chest – Symmetrical, no deformities, no trauma, Respirations unlabored and no use of accessory muscles noted. Lat to Ap diameter 2:1. Non-tender to palpation throughout.
Lungs – No wheezing, rales, stridor, or rhonchi. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus symmetric throughout.
Cardiac Exam
Heart: PMI in 5th ICS in midclavicular line. Carotid pulses are 2+ bilaterally without bruits. Regular rate & rhythm. S1 & S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.
Abdominal Exam: Abdomen flat and symmetric, and no scars, striae, or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/iliac or femoral bruits. Pt is non-tender to palpation in all four quadrants. (-) guarding. (-) obturators sign, (-) psoas signs, (-) rebound tenderness. No hepatosplenomegaly to palpation, no CVA tenderness appreciated.
Neurologic:
Mental status: Patient is alert. Cranial nerves II-XII intact. Recent and remote memory is intact, attention, abstract thinking, and new learning ability are intact. Pt has good muscle bulk and tone with strength 5/5, no fasciculations. Cerebellar: Rapid alternative movements, finger to nose intact. Gait including normal stride, on toes, on heels, and tandem walking intact. Negative Romberg and Pronator Drift. Sensory: Pinprick, light touch, graphesthesia, stereognosis, position and vibration intact bilaterally.
Reflexes:
| Biceps | Triceps | Brachioradialis | Patellar | Ankle/Achilles | Babinski | |
| Right | 2+ | 2+ | 2+ | 2+ | 2+ | absent |
| Left | 2+ | 2+ | 2+ | 2+ | 2+ | absent |
Peripheral Vascular: Extremities are normal in color and temperature, no edema. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing or cyanosis. No stasis changes or ulcerations noted.
Musculoskeletal (Upper Extremity): No soft tissue swelling / erythema /
ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted throughout. FROM of all upper and lower extremities bilaterally. No evidence of spinal deformities.
Assessment:
12 y/o male with a history of styes in the past presents with 3 days of right upper eyelid swelling, erythema, and mild discharge most consistent with a hordeolum most likely due to poor lid hygiene.
Differential Diagnosis After:
Hordeolum – pt had no pain with EOM, nasal congestion, orbital edema or vision changes. Erythema and swelling localized to eyelid.
Plan:
Start Augmentin 8.6 mL by mouth twice a day for 7 days and topical erythromycin ointment 1 inch ribbon 4 times a day for 7 days. Recommend warm compresses 5-10min twice a day and proper lid hygiene. Ophthalmology referral given to patient to follow up in clinic. Supportive care instructions and strict follow up precautions for which to return were given.
