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Documentation of an Assessment of the Head, Ears, and Eyes
Department of Nursing, Rasmussen University
NUR2180: Physical Assessment
Prof. Laura Buchanan, MSN
May 9th, 2021
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Subjective
Patient is a 27-year-old Asian male with a chief complaint of pink eye to left eye. Patient appears
to be alert and oriented. Patient is sitting in a hunched over position with hand over eye. Patient
stated he is experiencing eye discomfort in left eye. Patient states they have put eyedrops in their
left eye, which did not alleviate the discomfort. Patient’s left eye problem began yesterday.
Patient denies knowing anyone that has conjunctivitis. Patient states the discharge from the left
eye is constant and watery like. Patient denies discharge from right eye or discomfort. Patient
denies coughing, fever, sore throat, nasal congestion, and sneezing. Patient reports the pain at a
3/10. Patient states lying down, and cold compresses lower the pain to a 1/10. Patient state
standing out in the sun worsens pain to a 6/10. Patient denies double vision or halos. Patient
denies the use of contact lenes or glasses. Patient states vision is blurred in left eye. Patient has
difficulty keeping left eye open.
Patient has a history of hypertension. Family history: stroke (father, current age 55,alive),
hypertension (mother, current age 57,alive). Patient denies any surgical history. Denies any past
hospitalization. Patient denies any recent trauma. He states that he does not have any
environmental/ medication induced allergies. Patient denies smoking, consumption of alcohol, or
use of recreational drugs.
Objective
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Patient’s eyebrows have even hair distribution bilaterally. Patients right eye no lesions, redness
or masses. Patient’s right eyelid no swelling or redness. Patients right eye conjunctival sack has
no excessive redness. No discharge comes out of right eye. Patient’s eyelashes symmetrical and
evenly distributed on both upper and lower eye margins with crust on left eye lashes upper and
lower. Patients left eye has no lesions, masses, or foreign bodies sighted. Patient has swelling of
the upper eyelid on left eye. Patients’ left eye sclera has redness and inflammation. Patient’s left
eye has water discharge coming out of eye by the lacrimal gland. Patient has excessive redness
of the conjunctival sack on left eye. Patient’s pupils are a 4+ bilaterally they are round, reactive
to light, and accommodate to near and distant objects. Patient’s eyes can move in all 6 cardinal
directions of gaze; no nystagmus noted. A visual acuity test was performed on the Snellen chart
Patient’s left eye is at 20/70 on left eye and 20/20 on right eye.
Risk Factors
Patient is at risk for spreading conjunctivitis to other people in their household as the condition is
very contagious. Patient is at risk for future heart disease due to their history of hypertension.