soap note

SOAP NOTE

Name: NSDate: 01/18/18Time: 10:45 AMPt Encounter Number:N/A
 Age: 25Sex: F
SUBJECTIVE
CC:   “My eyes are swollen, red and painful”
HPI: Patient is 25-year-old female came to the office today with chief complaint of bilateral eye redness accompanied by inflammation and itching with greenish discharge worsening in the morning when ayes are glued by the secretions. Patient states the complaint started three days ago with her left eye affected first, and the following day her right eye started with the same symptoms. Discomfort rated 4/10.
Medications:None
PMH– Appendectomy (2008)Allergies:  NKDA, NKA to food, latex.Medication Intolerance: NoneChronic Illnesses/Major traumas: NoneHospitalizations/Surgeries: Appendectomy (2008)Immunizations: Up to date 
Family HistoryMother- 47 y/o: Healthy (Alive)Father: 49 y/o: HTN (Alive)Brother: 22 y/o: No health issues (Healthy)(Alive)Maternal Grandmother 69 y/o- HTN (Alive)Maternal Grandfather- 70 y/o HTN; Asthma (Alive)Paternal Grandmother- 71 y/o HTN; Hypothyroidism (Alive)Paternal Grandfather- 70 y/o Diabetes, Hypertension (Alive) 
Social HistorySmoking/Use Tobacco: NoUse Alcohol: No- Substance abuse/Use Drug: NoViolence or abuse in the home: (including physical, psychological or sexual abuse): NoCaffeine intake: NoSexually active: YesOccupation: College StudentMarital status: SingleLive with: FamilyChildren: None
ROS
GeneralNegative (Night sweats, weakness, malaise, chills or fever)CardiovascularNegative (Negative for chest discomfort, tachycardia or inflammation of lower extremities) 
SkinNegative (Negative for wounds, skin discolorations, rash, itching) RespiratoryNegative (Shortness of Breath, Cough, Sputum, Wheezing, Pleuritic Pain, Snoring, Hemoptysis, Daytime sleepiness) 
EyesPositive (bilateral eye redness, pain and greenish discharge and eyelid swelling)Negative (Vision change, Glasses/Contacts) GastrointestinalNegative (Nausea, Vomiting, Constipation, Bright red stool, Diarrhea, Heartburn, Melena, Increase Girt, Easy fullness, Hematemesis, Jaundice) 
EarsNegative (Hearing Loss, Tinnitus, Discharge, Vertigo, Earache, Ear fullness) Genitourinary/GynecologicalNegative (Change in urine color, urgency, incontinence, foul smelling urine) 
Nose/Mouth/ThroatNegative (Nose bleed, Sneezing, Stuffiness, Sinus pain, Sore Throat, Dysphagia, Running nose) MusculoskeletalNegative (Joint or muscle pain or swelling)
BreastDeferredNeurologicalNegative (Seizures, Syncope, Paresis, Speech difficulty, Tremor, Unsteady gait)
Heme/Lymph/EndoNegative (Anemia. Easy bruising, Thrombocytopenia, Excessive bleeding, Transfusion reactions, Night sweats, Swollen glands, Increase thirst, Increase hunger, Cold or heat intolerance, Goiter, Hair loss)PsychiatricNegative (Depression, sleeping difficulties, suicidal ideation, Hallucinations)
OBJECTIVE
Weight: 120 Lbs      BMI: 20 (Normal)Temp: 97.9BP:120/76
Height: 5’05”Pulse: 75Resp: 18
General AppearancePleasant and well developed, Hispanic female, well-nourish, well groomed, normal body habitus, no deformities, gait is normal, posture is normal. Alert and oriented; answers questions appropriately.
SkinSkin is warm and intact. Turgor is good. Capillary refill 2 seconds.
HEENTHead is atraumatic and normocephalic. Pupils equal round and reactive to light and accommodation. Non-iceric sclera with red conjunctivas. Bilateral diffuse redness and discharge. Mild bilateral eyelids swelling. Negative for subconjunctival hemorrhage. Moist mucosa, normal tonsils and adenoids and normal tongue. Neck is supple, trachea is midline, no carotid bruit or masses.
CardiovascularRegular rate and rhythm, S1S2 normal, no murmurs, no gallops. Point of maximum impulse (PMI) @4TH intercostal/midclavicular line.
RespiratorySymmetric chest wall. Respiration regular and easy; lungs clear to auscultation and normal percussion bilaterally.
GastrointestinalSoft, non-tender, non-distended, positive bowel sounds in the four quadrants, norebound, no guarding, no organomegaly. LBM 01/16/18.
BreastDeferred
GenitourinaryNo bladder distention or CVA tenderness. LMP 12/25/17.
MusculoskeletalFull ROM seen in all 4 extremities; Good muscle tone and correct spinal posture.
NeurologicalAAO x 4. Intact CN I-XII. No neuro focal deficits appreciated
PsychiatricNormal mood and affect. Able to maintain engagement throughout exam. No s/s of depression or anxiety
Lab TestsNone
Special TestsNone
 Diagnosis
 Differential Diagnoses1- Dry eye syndrome of unspecified lacrimal gland- H04.129: Is a multifactorial disorder characterized by abnormalities in the tear film and ocular surface leading to symptoms of irritation, discomfort, and visual disturbance (Buttaro et al, 2013)2- Retained foreign body in unspecified eye, unspecified eyelid- H02-819: The most common symptom of foreign body is severe eye pain in the affected eye. Some patients may present with a foreign body sensation instead of severe pain. Other symptoms include blurred vision, redness, tearing, light sensitivity, eyelid swelling, and blepharospasm (Buttaro et al, 2013)3- Other conjunctivitis- H10.89: is inflammation of the conjunctiva, the transparent mucosal tissue that lines the eye and inner surface of the eyelids. Commonly referred to as pink eye, conjunctivitis actually consists of many different disorders. Infectious causes include viruses and bacteria. Allergic, atopic and vernal, and toxic conjunctivitides are noninfectious (Buttaro et al, 2013)Ocular symptoms include acute onset of a red eye with excessive watery discharge. Itching, photophobia, watering, and foreign body sensation can be present. Patients can often recall the precise moment when symptoms began. Classically, it begins in one eye and then involves the fellow eye within days. Approximately half of patients will have bilateral involvement (Buttaro et al, 2013)Diagnosis– Other conjunctivitis- H10.89
Plan/Therapeutics
Plan:– Polymyxin B/trimethoprim ophthalmic 0.5% 1 drop into the affected eye four times daily.- Cold compresses to be applied to affected eyes 4-6 times per day.Education:– Discussed with patient risk and benefits of medication.-Take medications as prescribed, do not exceed the recommended dosage; do not stop even if symptoms improve.- Eyes can be clean in the morning from inner to outter canthus using a warm cloth that must not be re-used until washed throughout.- Patients should avoid touching their eyes, shaking hands with others, sharing towels or bedclothes, and swimming in public pools.-Patient instructed on the importance of hands washing with antimicrobial soap to avoid the spread of the disease.- Patient instructed to follow up in a week or contact healthcare provider if symptoms do not improve or continue to worsen.

Reference

Buttaro, T. M., Trybulski, J., Bailey, P. P., & Sandberg-Cook, J. (2013). Primary care: A

collaborative practice (4th ed.). [Vitalsource bookshelf online]. Retrieved from

https://digitalbookshelf.southuniversity.edu/#/books/978-0-323-07501-5/
 

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