CHART NOTE
SUBJECTIVE
This 36-year-old woman presents with the complaint of tearing and irritation of the left eye for about 48 hours. She has a thick mucous discharge which sticks the lids together overnight. Vision seems okay except for some blurring by mucus. She denies trauma or prior ocular pathology. She denies any symptom of URI or allergy and does not wear contact lenses or glasses. She denies photophobia. She has not been around anyone with pinkeye.
OBJECTIVE
The conjunctiva of the left eye is diffusely hyperemic, and there is moderate chemosis and lid edema. Traces of a mucopurulent discharge are evident on the lid margins and lashes. Exam with Pontocaine and fluorescein reveals no corneal abrasion or ulceration. No foreign bodies are noted on the palpebral conjunctiva or on the globe. Pupil is round and reactive. The ocular fundus is entirely normal. Slit-lamp exam shows no pathology in the cornea, anterior chamber, or lens. Tonometry is deferred. Far-point vision testing with the Snellen chart is 20/20 in each eye.
ASSESSMENT
Acute bacterial conjunctivitis, OS.
PLAN
1. Sulamyd ophthalmic solution, 2 drops OS q.i.d.
2. Treat OD also at first sign of symptoms there.
3. Cold compresses OS ad lib for comfort.
4. Careful handwashing and avoiding close personal contact for 24 to 48 hours.
5. Return p.r.n.
FOOTNOTE
Lines 29, 33. OS (left eye) and OD (right eye) are standard abbreviations used by ophthalmologists and need no translation.
Lines 35, 36. Alternative: 24-48.
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