Subjective Data Analysis
Subjective data includes a detailed history of the present illness, chief complaint, past medical history, family and social history, as well as review of systems. All necessary data related to the symptoms are identified, collected, and organized using the appropriate format. The history of disease development was described in details. All needed data and facts were included, and proper documentation was analyzed. Finally, a patient’s ethnicity and cultural background were identified.
It is possible to assume that a person has bacterial conjunctivitis. It is the inflammation on eye conjunctiva caused by bacterial infection. The condition is more common among children. However, the adults might also develop it. Diagnosis of bacterial conjunctivitis is based on the results of physical assessment and laboratory diagnostics (Silvester et al., 2017). Thus, the illness is bacterial infection that affects the eyes.
Infectious conjunctivitis is also considered highly contagious (Teweldemedhin, Gebreyesus, Atsbaha, Asgedom, & Saravanan, 2017). The patient lives with her boyfriend. In subjective data, information about whether a boyfriend has symptoms of bacterial conjunctivitis was not provided. Finally, the woman stated that she has had multiple episodes of throat infection during her childhood. The treatment of these infections was not clarified. Inappropriate care with antibiotics might cause appearing resistant bacterial strains (Silvester et al., 2017). Thus, all missed data should be collected from a patient.
Objective Data Analysis
Objective data presents the results of patient’s assessment. All needed data was collected and organized using the appropriate format. The pertinent facts were incorporated, and proper documentation was used. All systems of organs were assessed. Based on the symptoms of the disease, bacterial conjunctivitis could be supposed. It is the inflammation of the conjunctive mucosa cause by a range of Gram positive and Gram negative bacteria. The symptoms of the infection include red color of white eye, conjunctiva swelling, itching, feeling of a foreign body in the eye, tear production, pus discharge from the eyes, as well as crusting on eyelids (CDC, 2017). All symptoms were identified during the physical examination.
In the assessment, current diagnoses with code, differential diagnoses, and the list of risk factors were provided. Proper documentation was used. However, current diagnosis and differential diagnoses were not grounded with the information from subjective and objective data section. The relevant data was not filtered from irrelevant. No trends and relationship in data were identified. Risk factors were listed but not discussed in relation to diagnoses.
Regarding the diagnostic procedure, only microscopic examination and bacterial culture were mentioned. However, it would be appropriate to include antibiotics resistance test, as the infection might be caused by resistant bacteria (Silvester et al., 2017). The symptoms and physical assessment indicate conjunctivitis. More likely, the patient has bacterial conjunctivitis, as pus discharge from the eye is more common for bacterial infection (CDC, 2017). However, viral and allergic conjunctivitis should be also included in the list of differential diagnoses as well as endophthalmitis (Teweldemedhin et al., 2017). Thus, the list of differential diagnoses is not complete.
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Next, the risk factors should be listed in accordance with the patient’s history. In adults, the disease is associated with several risk factors, including previous eyes infection, contact with infected people, eyes injuries or surgery, the use of contact lenses, and dry eyes (Teweldemedhin et al., 2017). Importantly, the contact with sexually transmitted diseases was the risk factor (Khattab & Abdelfattah, 2016). Among these risk factors, only contact lenses and contact with infected people were mentioned. Other possible risk factors were missed.
Antibiotics might be used to treat bacterial conjunctivitis. The recommended care includes the use of eye drops containing antibiotics, including Trimethoprim/polymyxin 1 to 2 drops in each eye, four times per day for one week (Grzybowski, Brona, & Kim, 2017). It is also important to complete the full course of therapy (Silvester et al., 2017). Thus, the use of antibiotics allows to decrease of the disease duration and preventing chronic conjunctivitis development.
The plan included the recommendation only for bacterial conjunctivitis treatment, while therapy for other differential diagnoses was not considered. Still, the plan for the principal diagnosis treatment included pharmacological and non-pharmacological recommendations and recommendation for a follow-up visit. Pharmacological treatment and non-pharmacological therapy were appropriate for this condition (Grzybowski et al., 2017). No information regarding pharmacodynamics and interaction of drug with other medications was provided. Still, the data was not applicable since the patient does not use other pharmaceuticals. Education of the patient included the data for the correct use of eye drops, prevention of the disease spread, and possible early signs and symptoms of the disease, which are the most important issues regarding the problem (Watson, Cabrera-Aguas, & Khoo, 2018). Thus, education and treatment recommendations were appropriate and correspond with evidence.
No referrals were provided. It would be necessary to recommend the patient gynecological assessment and screening for STD (Khattab & Abdelfattah, 2016). It would also be important to provide the referral to ophthalmologists for visual assessment for possible complications.
Another important issue is patient’s cultural background. In this case, the woman was Hispanic. However, she was born in the United States. Thus, no language barrier possibly exists. Next, no ethnical predisposition to the disease is present. Finally, Hispanic people tend to use traditional medicine for treatment. It is needed to discover if the patient uses some traditional approaches to discuss possible harm and positive effects of it.
The case study presents the SOAP note on bacterial conjunctivitis. In general, subjective and objective data were presented appropriately as well as included all needed information. However, the assessment part requires improvements. First, not all risk factors were considered. Second, not all possible differential diagnoses were included in the list, and no relationships between diagnoses and patients’ subjective and objective data were provided. Still, the prescribed treatment was appropriate and based on the evidence.
It is possible to learn that the assessment is needed to be more detailed and grounded. The various differential diagnoses should be considered while assessing the patient. It would be necessary to provide referrals to ophthalmologists and gynecologists and prescribe laboratory analysis for antibiotic resistance.
Finally, plan did not include cultural considerations. However, it might not be necessary, as conjunctivitis is not related to patient’s cultural background. Thus, there is no evidence of the predisposition of ethnical minorities to this disease.
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