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Eye Itching Emergency Room Transcription Sample Report

CHIEF COMPLAINT:  Bilateral eye itching.

HISTORY OF PRESENT ILLNESS:  This is a (XX)-year-old Hispanic female who presents to the emergency department complaining of a 3-day history of eye itching and swelling. The patient states this started in her right eye 3 days ago and spread to her left eye yesterday. Today, both eyes have been bothering her. The patient states it is a little sore around her eyes, but her main complaint is that they are itchy. She has had some clear tearing but no purulent discharge. She states her right eye is a little bit more blurry than usual. She has no eye pain. No sneezing. No runny nose. She had similar symptoms to these a year ago. They were somewhat milder, and she did not seek medical attention. She denies any cough. She denies any pain with eye movement. She denies any foreign body sensation and denies any injury.

PAST MEDICAL HISTORY:
1.  Diabetes.
2.  Hypertension.

ALLERGIES:  None.

CURRENT MEDICATIONS:  Per medical reconciliation form.

FAMILY HISTORY:  Noncontributory.

SOCIAL HISTORY:  Positive for one pack per day tobacco use, occasional alcohol use. Negative for illicit drug use.

REVIEW OF SYSTEMS:  Negative for fevers, chills, nausea, vomiting, diarrhea, constipation, headache, visual disturbances, neck pain, chest pain, shortness of breath or abdominal pain. All other systems are negative, except as noted in the HPI.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Blood pressure 118/76, pulse 74, respiratory rate 18, temperature 98.4, pulse ox 98% on room air.
GENERAL:  The patient is awake, alert and oriented, in no apparent distress, resting comfortably on the bed.
HEENT:  Atraumatic and normocephalic. Pupils are equal, round, react to light. Extraocular movements are intact. Sclerae nonicteric. Conjunctivae are clear; although, she does have some clear chemosis present bilaterally. The patient has no pain with palpation over the globe itself. In her periorbital soft tissues, she has redness and swelling present, but it is not cellulitic redness; it is more of an irritated allergic reaction redness. She has no tenderness to palpation around her eyes. She has no purulent drainage. The oropharynx is clear. Pink and moist mucous membranes.
NECK:  Supple, no lymphadenopathy, no thyromegaly. Trachea is midline.
LUNGS:  Clear to auscultation bilaterally.
NEUROLOGIC:  She is intact. Moving all four extremities symmetrically and spontaneously and following commands. Her left eye was tested. Visual acuity was tested and is 20/50. Her right eye visual acuity was 20/50 as well.
SKIN:  Warm and dry. No evidence of rash other than is noted around the eyes.

LABORATORY RESULTS/RADIOLOGY:  None.

EMERGENCY DEPARTMENT COURSE:  The patient was seen and evaluated. She remained hemodynamically stable throughout her stay. She received 50 mg of Benadryl and was discharged home.

MEDICAL DECISION MAKING:  The patient presents with evidence of urticaria and allergic-related eye swelling. She has no evidence at this time of periorbital cellulitis, preseptal cellulitis or retro-orbital cellulitis. She has no evidence of ocular pain to suggest that she would have acute angle glaucoma. This would be unusual in both eyes anyway. She has no evidence of ruptured globe. No evidence of acute trauma and no evidence of cellulitis at this time. She is hemodynamically stable for discharge.

IMPRESSION:  Urticaria.

PLAN:
1.  The patient is to take Benadryl and Claritin as needed.
2.  The patient is to follow up with her clinic, both for this and for medication refills that she is going to need in the near future.
3.  She is to return for significant worsening of her symptoms, development of eye pain, worsening of her redness or swelling despite therapy or other concerns.
4.  The patient verbalized understanding of the discharge instructions.

DISPOSITION:  Discharged home in good condition.

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