ANSWER
Note in SOAP:
Subjective:
The primary complaint of a 27-year-old woman is that both of her eyes are red, itchy, and crusty.
Present Illness History (HPI): According to the patient, the symptoms began about two days ago. When she wakes up, she observes crusting around her eyes and describes the redness in them as being both dry and itchy. Other than the crusting, she denies any pain, discharge, or changes in appearance. She adds that she has experienced some minor eye irritation when blinking.
Medical History: There is no notable history of eye issues. Any prior bouts of conjunctivitis are denied by the patient.
Social History: The patient describes having a close relationship with youngsters while working as a teacher. She denies drinking or smoking. No recent travel history or exposure to people exhibiting similar symptoms is known.
Family History: There is no history of eye conditions in the family.
Medication: Not taking any at the moment.
No known medication allergies exist.
Goal:
Vital signs: temperature (98.7°F), RR 16, HR 78, and BP 120/78
Overall Appearance: The woman appears well and is not in any immediate difficulty.
HEENT:
Eyes: Mild eyelid edema and bilateral conjunctival redness. The lower eyelids exhibit obvious crusting, which is especially noticeable in the morning. Other than crusting, no discharge was seen. No visual impairment or involvement of the cornea. There is no tenderness when the eyes are palpated.
Ears: Standard examination.
Nose: Clear, with no discharge or congestion.
Throat: No exudates or erythema were observed.
There is no detectable lymphadenopathy in the lymphatics.
Skin: Free of lesions or rashes.
Evaluation:
Pink eye, or viral conjunctivitis, is the most likely diagnosis.
In addition to the absence of noticeable discharge, the patient’s symptoms—which include eye redness, itching, and crusting—indicate viral conjunctivitis. This view is supported by the patient’s modest symptoms and the lack of discomfort or visual abnormalities. Normal vital signs and the absence of systemic symptoms (fever, severe malaise) further point to a benign viral origin.
Differential diagnosis:
The typical symptoms of bacterial conjunctivitis include purulent discharge and more localized redness.
More common in those with a history of allergies, allergic conjunctivitis is characterized by watery discharge and symptoms that the patient does not disclose, such as sneezing or nasal congestion.
Plan:
Education: Explain to the patient that viral conjunctivitis is communicable and suggest good hygiene practices, such as frequent hand washing and avoiding eye contact.
advise staying away from close people, particularly during the initial days of illness.
To ease discomfort and lessen eye crusting, recommend applying a warm compress.
Administration:
Artificial Tears: To lubricate the eyes and reduce dryness, suggest using over-the-counter artificial tear drops.
Topical Antihistamines: If the itching is severe, you might want to suggest antihistamine eye drops (such the over-the-counter ketotifen 0.025%).
Steer clear of irritants: advise staying away from smoking and potent scents since they may make symptoms worse.
Follow-up: If symptoms worsen or continue, suggest a follow-up appointment in seven to ten days.
Reassessment for a possible bacterial infection may be considered if symptoms do not get better or get worse with more pain or discharge.
Referral: To rule out any corneal involvement, see an ophthalmologist for additional assessment if symptoms are severe or do not get better with conservative therapy.
Citations:
(2020) American Academy of Ophthalmology. conjunctivitis. taken from the website https://www.aao.org
CDC, 2019. viral ocular irritation. taken from the website https://www.cdc.gov
QUESTION
Patient is a 27 year old female
presenting with redness, itchiness, and eye crust eyes
patient has pink eye which in medical terms is conjunctiviti