3 – Eye

HISTORY: 
[checkbox name="historian" value="provided by patient|provided by family member||SO/family member present during visit|chaperon/MA present during visit||interpretation provided by family member/SO|interpretation provided by MA||complete history unobtainable d/t poor effort/affect|complete history unobtainable d/t cognitive changes or lack of knowledge|complete history unobtainable d/t language skills|"][textarea cols=70 rows=1]
CC:
[checkbox name="cc" value="pain|redness|burning|itching|discharge|matting||eyelid swelling|periorbital swelling|pain with EOM||trauma|foreign body sensation||decreased vision|decreased peripheral vision|decreased central vision|blurred vision|diplopia|scotoma|photophobia|"][textarea cols=70 rows=1]
AFFECTED EYE:
[checkbox name="affected" value="right|left|both|"][textarea cols=70 rows=1]
STATED CAUSE:
[checkbox name="cause" value="unknown|trauma|chemical exposure|welding arc|tanning booth/beach|foreign body|dust|metal particle|"][textarea cols=70 rows=1]
HPI:
[checkbox name="hpi" value="sudden onset|gradual onset||started just prior to arrival|started today|started yesterday|started days ago|started months ago||washed eyes at scene/home|doing compresses|applying ointment|sx increasing in severity|sx persist|sx decreasing in severity|"][textarea cols=70 rows=1]
PAST/RECENT HISTORY: [textarea cols=40 rows=1]
[checklist name="pmh" value="PCP visit|ER/UC visit|hospitalization|travel|sick contact|new/changed medications|antibiotic use|injury|glaucoma|eye surgery|connective tissue disease"]

REVIEW OF SYSTEMS:     [+] reported  [-] not reported
negative except as stated in HPI
CONSTITUTIONAL: [textarea cols=40 rows=1]
[checklist name="const_symptoms" value="objective fever|subjective fever|chills|fatigue|weight loss"]
EARS: [textarea cols=40 rows=1]
[checklist name="ear_symptoms" value="pain|pressure|discharge|bleeding|wax"]
ENT: [textarea cols=40 rows=1]
[checklist name="ent_symptoms" value="facial numbness|nasal discharge|bleeding|mouth sores|sore throat|hoarseness|earache"]
NECK: [textarea cols=40 rows=1]
[checklist name="neck_symptoms" value="pain|stiffness|swelling|swollen glands"]
CV: [textarea cols=40 rows=1]
[checklist name="cv_symptoms" value="chest pain/pressure|SOB|palpitations|dyspnea|orthopnea|ankle swelling|ankle discoloration|varicose veins|leg cramps"]
CHEST/RESPIRATORY: [textarea cols=40 rows=1]
[checklist name="chest_symptoms" value="chest tightness|pain w/ breathing|rib pain"]
GI: [textarea cols=40 rows=1]
[checklist name="gi_symptoms" value="poor appetite|nausea|vomiting|generalized abdominal discomfort|abdominal pain|constipation|diarrhea"]
GU: [textarea cols=40 rows=1]
[checklist name="gu_symptoms" value="dysuria|hematuria|itching|genital lesions"]
MSK: [textarea cols=40 rows=1]
[checklist name="msk_symptoms" value="neck pain|back pain|extremity pain|generalized joint pain|myalgias"]
NEURO: [textarea cols=40 rows=1]
[checklist name="neuro_symptoms" value="dizziness|vertigo|poor balance|abnormality of walk|focal weakness|blackouts|seizures|tingling/numbness"]
PSYCH: [textarea cols=40 rows=1]
[checklist name="psych_symptoms" value="irritability|confusion|depression|anxiety|mood swings|memory loss|insomnia"]
LYMPH/HEMA: [textarea cols=40 rows=1]
[checklist name="hem_symptoms" value="gland swelling|bruising|anticoagulation|DVT/clotting|anemia"]
ALLERGIES/IMMUNE: [textarea cols=40 rows=1]
[checklist name="allergy_symptoms" value="atopy|food allergies|autoimmune dz|h/o cancer"]
DERM: [textarea cols=40 rows=1]
[checklist name="derm_symptoms" value="dryness|pruritus|rash|hives|redness|swelling|wounds|new or suspicious lesions"]

---------------------------------------------------

Appearance:
[checkbox name="appearance" value="well-appearing|alert|non-toxic|normal WOB||allows exam|poor cooperation with exam|crying but consolable||ill-appearing|tired-looking|short of breath|diaphoretic||drowsy|appears impaired|slumped|"][textarea cols=70 rows=1]

Skin:
[checkbox name="skin" value="warm, dry|grossly intact, no rashes|no bruises|normal turgor|dry||tattoos|body piercings||pallor|cyanosis|poor turgor|diaphoresis|rash|"][textarea cols=70 rows=1]

Ears:
[checkbox name="ears" value="symmetrical & intact auricles bilaterally|hearing to conversation intact|clear canals without erythema or discharge|TMs normal in appearance||TM obscured by cerumen|TM red||mastoid tenderness|"][textarea cols=70 rows=1]

Nose:
[checkbox name="nose" value="nares patent bilaterally|septum midline|mucosa pink & moist||mucosal edema|clear discharge|purulent drainage|"][textarea cols=70 rows=1]

Mouth:
[checkbox name="mouth" value="moist oral mucosa without lesions||upper front teeth non-tender and immobile||upper denture|lower denture||dental decay|oral ulcers|"][textarea cols=70 rows=1]

Throat:
[checkbox name="throat" value="normal voice|patent pharynx w/o swelling or exudates|uvula midline||hoarseness|pharyngeal erythema w/o exudates|pharyngeal crowding||tonsillar enlargement|tonsillar erythema|tonsillar exudates|tonsillar crypts|tonsillar pustules|"][textarea cols=70 rows=1]

Neck:
[checkbox name="neck" value="symmetric with free painless ROM|no LAD||anterior LAD|posterior LAD||nuchal tenderness|"][textarea cols=70 rows=1]

Chest/Lungs:
[checkbox name="lungs" value="normal work of breathing, symmetrical chest expansion|no retractions|clear and equal breath sounds bilaterally||respiratory distress|breath sounds decreased|coughing|wheezing|crackles|poor effort|"][textarea cols=70 rows=1]

CV:
[checkbox name="cv" value="regular rhythm|no murmurs|no ankle edema||tachycardia|irregular heart rhythm|pedal edema|"][textarea cols=70 rows=1]

Abdomen:
[checkbox name="abd" value="not examined|normal visual inspection, no distension||normal active bowel sounds|soft non-tender|"][textarea cols=70 rows=1]

GU:
[checkbox name="gu" value="not examined||no suprapubic tenderness|no CVAT bilaterally||normal external genitalia|"][textarea cols=70 rows=1]

MSK:
[checkbox name="spine" value="no gross deformities, moves all extremities with good ROM for age|full weight-bearing|normal curvature & ROM spine for age|"][textarea cols=70 rows=1]

Neuro:
[checkbox name="neuro" value="ambulates w/o limp or alteration in gait|balance & coordination grossly intact|extremities strong w/o atrophy, tremor or fasciculations||normal speech|normal concentration and attention|memory grossly intact||no gross motor deficits|sensation symmetrical & grossly intact|"][textarea cols=70 rows=1]

Head/Face:
[checkbox name="head" value="normocephalic, atraumatic|symmetrical face|CN V intact|no facial/temple tenderness|no palpable orbital deformity/tenderness||periorbital swelling|periorbital tenderness|"][textarea cols=70 rows=1]

Visual Acuity:
[checkbox name="visual" value="grossly intact|with glasses|without glasses|20/20|"][textarea cols=70 rows=1]

EOM:
[checkbox name="eom" value="intact||nystagmus|palsy|dysconjugate gaze|"][textarea cols=70 rows=1]

Pupils:
[checkbox name="pupils" value="PERL|normal accommodation|normal reaction to direct and consensual light||dilated|constricted|anisocoria|irregular shape|ciliary flush|direct photophobia|consensual photophobia|"][textarea cols=70 rows=1]

Affected Eye - Globus:
[checkbox name="globus" value="non-tender||proptosis|tender|"][textarea cols=70 rows=1]

Affected Eye - Eyelids:
[checkbox name="lids" value="normal inspection||everted for exam||edema|erythema|ptosis|stye||no FB visible|FB in sulcus|"][textarea cols=70 rows=1]

Affected Eye - Conjunctiva/Sclera:
[checkbox name="conj" value="normal inspection||injection|epiphora|exudate|chemosis|pterygium|subconjunctival hemorrhage||no fluorescein uptake|fluorescein uptake|"][textarea cols=70 rows=1]

Affected Eye - Cornea:
[checkbox name="cornea" value="normal inspection|smooth||no fluorescein uptake|fluorescein uptake|"][textarea cols=70 rows=1] 

Affected Eye - Anterior Chamber:
[checkbox name="ant" value="normal inspection||hyphema|cloudy|"][textarea cols=70 rows=1] 

Affected Eye - Fundus:
[checkbox name="fundus" value="unable to examine||normal|abnormal|"][textarea cols=70 rows=1]

Unaffected Eye:
[checkbox name="good_eye" value="normal exam|abnormal: "][textarea cols=70 rows=1]

Behavior:
[checkbox name="behavior" value="calm, pleasant, respectful||cooperative with exam|uncooperative with exam||guarded|anxious|fearful|suspicious|hypervigilant||irritable|frustrated|restless||labile|sighing|crying||agitated|raising voice||defensive|argumentative|hostile||forceful|intense|euphoric||demanding particular medication, test, referral, or accommodation||withdrawn|indifferent|appears to be responding to internal psychotic process|"][textarea cols=70 rows=1]

Psychomotor Activity:
[checkbox name="psychomotor" value="no involuntary movements||tremor|tardive dyskinesia|tics||bradykinetic|fidgeting|picking skin|twirling hair|cracking knuckles||threatening posture/movement|grimacing, furrowing eyebrows|tightening jaw|breathing hard||shaking extremities|clenching fists|intense staring||standing up and/or pacing|opening door to hallway|exited exam room during exam|"][textarea cols=70 rows=1]

Speech/Vocalization:
[checkbox name="speech" value="normal rate & rhythm|clear & coherent||slurred|monotonous|stuttering||hypoverbal|hyperverbal||loud|soft||slow|rapid|pressured||repetitive questions|cursing, swearing|criticisms of staff|verbal threats|"][textarea cols=70 rows=1]

OFFICE DIAGNOSTICS:
[checkbox name="office" value="none||rapid strep NEG|"][textarea cols=70 rows=1]

IMAGING:
[checkbox name="order_imaging" value="none|X-ray|CT|facial series|orbital series||essentially normal|no orbital fx||staff to notify patient once radiology report becomes available|"][textarea cols=70 rows=1]

[comment memo="DX:
conjunctivitis
viral syndrome
eye pain
decreased vision
acute iritis
glaucoma
allergic conjunctivitis
corneal abrasion
corneal ulcer
foreign body
ultraviolet keratitis"]



A/P:
[textarea cols=70 rows=4]

PLAN OF CARE:
[checkbox name="discussed" value="POA risks/benefits/side effects/alternatives discussed with patient/parent/SO, opportunity provided to ask questions|verbalized understanding of and agreement with POC, discharge & f/u instructions||patient/family did not agree with my POA/recommendations – will seek second opinion/further care elsewhere|"][textarea cols=70 rows=1]

PROCEDURE:
[checkbox name="procedure" value="none||proparacaine applied|fluorescein dye applied|eye examined|no areas of increased uptake of fluorescent stain under cobalt blue||corneal FB removal attempted with cotton-tipped swab|corneal FB removal attempted with needle/burr||scleral FB removal attempted with cotton-tipped swab|scleral FB removal attempted with needle/burr||eye irrigated with NS|no FB material visible|EOM intact|cornea clear|rust ring remaining||visual acuity reevaluated post procedure - unchanged|"][textarea cols=70 rows=1]

RX:
[checkbox name="order_RX" value="none|paper|electronic|given to MA to be transmitted to pharmacy|"][textarea cols=70 rows=1]

REFERRALS:
[checkbox name="order_refer" value="none|ophthalmology|"][textarea cols=70 rows=1]

REVIEWED:
[checkbox name="reviewed" value="MA notes|med list|previous visits|previous laboratory/diagnostic studies|"][textarea cols=70 rows=1]

INSTRUCTED ON:
[checkbox name="instructions" value="vital signs/exam findings/recommendations|appropriate follow up & possible specialty consult if sx don't improve in 3 days|reporting medication side effects immediately|laboratory/diagnostic studies|"][textarea cols=70 rows=1]

BARRIERS TO CARE:
[checkbox name="barriers" value="none identified||poor cooperation with exam|lack of motivation|negative attitude to diagnostic impression & proposed tx|incomplete history|vague shifting complaints|history not supported by objective findings|parental anxiety||poor compliance with POC|multiple comorbidities|polypharmacy|lack of interest in nonpharmacologic therapies|overwhelming focus on Rx drugs|intolerance of multiple meds||frequent ER/UC visits|altered mental status|hostile/disruptive behavior|active psychiatric diagnosis|alcohol or substance use|social/cultural barriers|victim of abuse||tangential thinking|perseveration|flight of ideas||preoccupation with illness|catastrophization|overgeneralization|unrealistic beliefs|negativism|pessimism|blaming others|staff splitting||delusions|paranoid ideation|"][textarea cols=70 rows=1]

FOLLOW UP:
[checkbox name="follow" value="RTC as discussed, sooner if condition worsens or new symptoms arise, contact 911/ER if significant increase in s/sx or appearance of new/danger s/sx, PRN||24 hours|48 to 72 hours|"][textarea cols=70 rows=1]

DISPOSITION:
[checkbox name="disposition" value="home|referred to ER for immediate treatment via 911|referred to ER for immediate treatment via private transport||declined emergency transfer|left facility before being discharged|asked to leave clinic|"][textarea cols=70 rows=1]