How should I document bacterial conjunctivitis in a physical assessment?

How to Document Bacterial Conjunctivitis in Physical Assessment

Document bacterial conjunctivitis by recording laterality (unilateral or bilateral), bulbar conjunctival injection, and the character of discharge (purulent or mucopurulent), along with specific examination findings from slit-lamp biomicroscopy. 1

Essential Documentation Components

Chief Complaint and History

• Discharge character: Specify purulent or mucopurulent discharge that persists throughout the day, with eyelids matted shut upon waking 1, 2, 3
• Laterality: Document whether unilateral or bilateral presentation 1
• Duration and time course: Record onset timing and progression 1
• Exposure history: Note recent contact with infected individuals, especially in school settings 1
• Associated symptoms: Document presence or absence of pain, photophobia, blurred vision, and itching 1
• Systemic symptoms: Record any concurrent otitis media, sinusitis, pharyngitis, or upper respiratory infection 1

Physical Examination Findings

Visual Acuity

• Always measure and document visual acuity at presentation 1, 4

External Examination

• Preauricular lymphadenopathy: Palpate and document presence or absence 1
• Eyelid findings: Record swelling, discoloration, mattering, or adherence of eyelids 1
• Skin examination: Note any rosacea, eczema, or seborrhea 1

Conjunctival Examination

• Injection pattern: Document bulbar conjunctival injection and whether diffuse or sectoral 1
• Discharge: Specify purulent or mucopurulent character 1
• Conjunctival reaction type: Note if follicular or papillary reaction present, particularly on inferior tarsal conjunctiva 1
• Chemosis: Document presence and severity 1
• Hemorrhages: Record any subconjunctival hemorrhages 1

Slit-Lamp Biomicroscopy Findings

• Eyelid margins: Document inflammation, edema, meibomian gland dysfunction, or discharge 1
• Eyelashes: Note crusting, scurf, or lash loss 1
• Cornea: Critical to document corneal clarity and absence of infiltrates or ulcers 1, 3
• Anterior chamber: Record presence or absence of inflammatory reaction 1

Severity Classification Documentation

Mild Bacterial Conjunctivitis

• Document minimal to moderate conjunctival injection with purulent discharge but no corneal involvement 1
• Note that patient is immunocompetent 4

Moderate to Severe Bacterial Conjunctivitis

• Document copious purulent discharge, marked inflammation, and pain 1
• Record if gonococcal infection suspected based on marked eyelid edema, marked bulbar conjunctival injection, and hyperacute presentation 1
• Note any corneal infiltrate or ulcer, which often begins superiorly in gonococcal cases 1

Critical Red Flags to Document

Always explicitly document presence or absence of these findings, as they require immediate ophthalmology referral: 4, 2

• Visual loss or decreased vision 4, 2
• Moderate or severe pain 4, 2
• Corneal involvement (hazy cornea, infiltrate, or ulcer) 1, 4, 3
• Contact lens wear 4, 3
• Recent ocular surgery 4, 2
• Immunocompromised status 4, 2
• Vesicular rash on eyelids or nose (suggests HSV or VZV) 1, 2

Age-Specific Documentation Considerations

Neonates (Birth to 31 Days)

• Document time of onset after birth (gonococcal typically 1-7 days, chlamydial 5-14 days) 1
• Record maternal prenatal care history and delivery method 1
• Cultures are mandatory - document that specimens were obtained 1

Children

• Document exposure to infected individuals in school or daycare settings 1
• Note any concurrent otitis media, sinusitis, or pharyngitis 1
• Consider and document assessment for sexual abuse if gonococcal or chlamydial conjunctivitis diagnosed 1, 4

Adults

• Document contact with infected individuals, oculogenital spread risk factors, or unhygienic living conditions 1
• Record any lid malposition, severe tear deficiency, or immunosuppression 1

Common Documentation Pitfalls to Avoid

• Never document "conjunctivitis" without specifying laterality and discharge character 1
• Always document corneal examination findings - failure to identify corneal involvement leads to inadequate treatment 1, 3
• Do not assume mild presentation - document severity markers (copious discharge, marked inflammation, pain) to guide antibiotic choice 1
• Document response to previous treatments if this is a recurrent or persistent case, as this suggests possible MRSA 1