H&P 

   

History  

Identifying Data:   

Full Name: MR

Address: N/A   

Date of Birth: N/A   

Date & Time: 05/24/23, 11:00 am   

Location: CUC    

Religion: N/A   

Source of Information: Self 

Reliability: Reliable   

Source of Referral: Self   

Mode of Transport: N/A   

Chief Complaint: “I have pain behind my left eye” x 3 days. 

25 y/o male with PMH of HTN and asthma presents today for shooting pain behind left eye that began 3 days ago. Pt notes eye pain has progressively gotten worse and is only with extraocular movements from left to right and vice versa. Today pt woke up with eye redness, photosensitivity, and blurry vision.  Rates pain 7/10. He also notes he’s had cough and congestion for the past week, and some bleeding from his nose with sneezing. Has not taken any meds. Denies any foreign body sensation, discharge, itchiness, headaches, trauma, fever, chills, nausea, vomiting, diarrhea, ear pain, sore throat, recent sick contacts, or recent travel. 

Initial DDx: 

Orbital Cellulitis – can present with deep eye pain, orbital edema, proptosis, chemosis, pain with EOM, vision changes  

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  

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:  

Losartan Potassium for HTN. 

Allergies:  

NKDA   

   

Family History:  

Mother – 55 y/o, alive and well 

Dad – 53 y/o, alive, h/o HTN 

Maternal grandparents – alive and well 

Paternal grandparents – alive and well 

Denies family h/o cancer, asthma, kidney disease, diabetes. 

   

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 – Admits to occasional exercise.   

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, painful eye movements, visual disturbances, eye redness. Denies lacrimation, pruritus. 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) 133/85 (sitting)          P:  70 beats/min, regular   

    

R: 18 breaths/min, unlabored  

O2 Sat: 99 % on room air  

   

T: 36.7 degrees C (oral)   

   

Weight: 28 BMI  

   

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 – Left eye: orbital edema, erythema noted along lid margins, (+) conjunctival injection, pain with EOMs, proptosis. No discharge present, induration, not warm to touch. No strabismus or ptosis.  Cornea clear, conjunctiva pink. Visual acuity uncorrected – 20/0 OS, 20/30 OD,  20/20 OU. Visual fields full OU.  PERRLA, EOMs intact with no nystagmus.    

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 gray/infarct with light reflex in good position 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. No leukoplakia.    

Palate – Pink; well hydrated. Palate intact with no lesions; masses; scars. Continuity intact.    

Teeth – Good dentition / no obvious dental caries noted.    

Gingivae – Pink; moist. No hyperplasia; masses; lesions; erythema or discharge.  

Tongue – Pink; well papillated; no masses, lesions or deviation.    

Oropharynx – Well hydrated; no injection; exudate; masses; lesions; foreign bodies.    

Tonsils present with no injection or exudate. Uvula pink, midline, 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: 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:  

25 y/o with PMH of HTN and asthma with conjunctival injection, painful EOMs, orbital edema and proptosis most consistent with orbital cellulitis.   

Differential Diagnosis After: 

• Orbital Cellulitis – Patient presented with painful EOMs, blurry vision, eyelid swelling, and proptosis. Patient had also been congested for 1 week.

Plan: 

Discussed concern for possible orbital cellulitis diagnosis. Recommended patient to go to the ED emergently for IV antibiotics and orbital cellulitis work up. Patient expressed understanding and ambulated freely on his own to ED. Suggested follow up with Ophthalmology within 3-4 days. Supportive care instructions and strict follow up precautions for which to return were given.