Care plan eye infection

Anonymous
timer Asked: Apr 21st, 2017

Question description

67 year old white male seen in office 4/20/2017 case log number 4494203

Chief Complaint

Pt. is here for a problem with his eyes being red, itchy and some drainage since Sunday. He also needs to discuss his prescriptions because of insurance changes.

History of Present Illness

Patient complaints of itchy red eyes billaterally

Review of Systems

Constitutional: [No fevers, chills, sweats]

Eye: [No recent visual problems]

ENT: [No ear pain, nasal congestion, sore throat]

Respiratory: [No shortness of breath, cough]

Cardiovascular: [No Chest pain, palpitations, syncope]

Gastrointestinal: [No nausea, vomiting, diarrhea]

Genitourinary: [No hematuria]

Physical Exam

Vitals & Measurements

HR: 68 (Peripheral) RR: 16 BP: 142/90 SpO2: 98%

General: [Alert and oriented, well nourished, no acute distress].

Eye: [PERRL, EOMI, red and itchy conjuctiva].

HENT: [Normocephalic, clear tympanic membranes, normal hearing, moist oral mucosa, no scleral icterus, no sinus tenderness].

Neck: [Supple, non-tender, no carotid bruits, no JVD,].

Lungs: [Clear to auscultation , non-labored respiration].

Heart: [Normal rate, regular rhythm,].

Abdomen: [Soft, non-tender, non-distended, normal bowel sounds, no masses].

Musculoskeletal: [Normal range of motion and strength, no tenderness or swelling].

Skin: [Skin is warm, dry and pink, no rashes or lesions].

Neurologic: [Awake, alert and oriented X4,].

Psychiatric: [Cooperative, appropriate mood and affect].

Assessment/Plan

1. Viral eye infection H44.009

Orders:

ciprofloxacin ophthalmic, 2 drop(s), OPTH, q4hr, X 7 day(s), # 5 mL, 0 Refill(s), 04/27/17, Pharmacy: Express Scripts Home Delivery, two drops bilateral bid, 2 drop(s) OPTH q4hr,x7 day(s)

Problem List/Past Medical History

Ongoing

Asthma

Hyperlipidemia

Hypertension

Osteoarthritis

Viral eye infection

Historical

No qualifying data

Medications

Anoro Ellipta 62.5 mcg-25 mcg/inh inhalation powder, 1 puff(s), INH, Daily, 2 refills

Aspirin Low Dose, Oral, Daily

ciprofloxacin 0.3% ophthalmic solution, 2 drop(s), OPTH, q4hr

Clarinex 5 mg oral tablet, 5 mg, 1 tab(s), Oral, Daily, 1 refills

Flomax 0.4 mg oral capsule, 0.8 mg, 2 cap(s), Oral, Daily

lisinopril 10 mg oral tablet, 10 mg, 1 tab(s), Oral, Daily

LORazepam 1 mg oral tablet, 1 mg, 1 tab(s), Oral, BID

montelukast 10 mg oral tablet, 10 mg, 1 tab(s), Oral, qPM, 1 refills

oxaprozin 600 mg oral tablet, 600 mg, 1 tab(s), Oral, BID, 1 refills

potassium chloride extended release, Oral

ProAir HFA 90 mcg/inh inhalation aerosol, 2 puff(s), INH, Once, PRN

simvastatin 10 mg oral tablet, 10 mg, 1 tab(s), Oral, Once a day (at bedtime), 1 refills

Allergies

HYDROcodone

Social History

Alcohol - Denies Alcohol Use

Exercise - Regular exercise

Tobacco - Denies Tobacco Use

Complete Subjective Information
PMH, PSH, FH, ROS completed. Provide complete and concise summary of pertinent information.

2

Complete Objective Information
Complete physical exam with critical elements related to subjective data.

2

Perform Assessment
Minimum of 3 differentials supported by S + O data. Final diagnosis noted and optimal and thorough subjective and objective assessment is presented for final diagnosis.

2

Create a Plan
Plan includes pharmacologic and nonpharmacologic treatments as well as education provided. The plan is supported by evidence/guidelines, and the follow-up plans are noted.

2

Self Assessment & Clinical Guidelines
Analyze quality and relevance of S + O data and the evidence for diagnosis. Use of clinical evidence based reasoning and literature in designing plan of care, compare to plan of care.

2

Total:

10

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