NR511 Wk1 SOAP-Mary Smith

NR511 Wk1 SOAP-Mary Smith

NR511 Wk1 SOAP-Mary Smith

Patient #1:  Mary Smith, 44 y/o Caucasian female

Subjective:

CC:  “This morning I had all this goop in my eye when I woke up and I noticed my eye looks red too.”

HPI:

Onset:  This morning.  Any prior illnesses or symptoms?

Location:  Only in one eye.  Which eye, L or R?

Duration:  Since this morning.  Are symptoms constant?

Characteristics:  Goop in one eye when woke up this morning and eye looks red.  What is the appearance of the goop, color, consistency, and amount?  What part of the eye looks red and is it the entire eye?

Aggravating factors:  None stated.  Does anything make the goop or color worse or cause the affected eye to feel itchy or burning?  Is there any other sensation such as pressure or pain?  Nothing seems to make the eye drainage worse.

Relieving factors:  None stated.  Does anything relieve the goop or improve the red color?  Nothing seems to make the eye drainage better.

Treatment:  None stated.  Have you taken any medications for the affected eye or applied any eye drops, or used any therapeutic interventions such as warm compresses?  Has not tried any home treatments.

Severity:  None stated.  Does the affected eye hurt and if so, what is the pain rating, and describe the pain?  Does affected eye have any itching or burning?  Is vision or eye movement affected?  Does the affected eye make it harder to perform work functions or make it harder to drive an automobile?  Did not go to work today because she thinks she might infect her coworkers. 

Additional Questions:  Has she been around anyone besides Mary Kate that she noticed had pink or red eye at work or anywhere?  Does she have any history of eye infections or getting sick?

NR511 Wk1 SOAP-Mary Smith

Current Medications: Daily multivitamin and B complex supplement.

Allergies:  NKDA.  Does she have any food or environmental allergies?

PMHx:  Denies past illnesses or injuries.  Hospitalized x 2 for childbirth.  No surgeries.  When was last tetanus?  Up to date on vaccinations such influenza?

Soc Hx:  H.S. graduate and is employed full-time with local business in the ordering department.

Fam Hx:  Married and lives with husband, Patrick, who is a full-time electrical engineer.  In addition to Mary Kate, they have a 10 y/o son Michael, 4 y/o twin boys Paddy and Tommy, and Mary’s parents, Katie and John, who live with them and help with childcare.  Patrick and John smoke but not in the house.  Mary has two siblings in good health.  Patrick is an only child and his parents died in their 70s.  Katie has hx of HTN and hyperlipidemia.  John has hx of tobacco use since 10 y/o, HTN, and hyperlipidemia.  They also share home with 2 dogs and a cat.

ROS: 

Constitutional/General:  Do you have any weight loss, fever, chills, weakness, or fatigue?  Denies fever. 

HEENT:  Head:  Any head trauma or alopecia?   Headaches?  Denies headache.  Eyes:  Any trauma to eyes, lids, or around eyes?  Do you wear glasses or contacts?  Changes in vision or sensation?  Denies vision changes.  Drainage?  Abnormal dryness?  Ears:  Any trauma to ears?  Change in hearing or loss of hearing?  Abnormal sounds like ringing?  Drainage?  Denies ear pain, hearing loss, and ringing in ears.  Nose:  Any trauma to nose?  Loss of sense of smell?  Pressure, congestion or drainage?  Trouble breathing through nose?  Denies nasal congestion and discharge.  Throat:  Any sputum production?  Mouth ulcers, other sores, or bleeding?  Difficulty swallowing or soreness?  Denies sore throat and difficulty swallowing.  

Neck/Lymphatic:  Any trauma to neck?  Swelling or tenderness in areas of neck or around jaw?  Denies enlargement of lymph nodes.

Cardiovascular:  Any chest pain, prior heart attack, high blood pressure, irregular pulse or the feeling of the heart racing or palpitations, or swelling of extremities?  Denies chest pain, palpitations, and dizziness.

Respiratory:   Any cough, SOB, wheezing, or pain upon inspiration or expiration?  Denies wheezing, SOB, and cough.

Abdominal:  Any pain, nausea, vomiting, diarrhea, or change in bowel movements?

NR511 Wk1 SOAP-Mary Smith

Objective:  (Physical Exam)

Constitutional/General:  Alert, oriented and cooperative.  VS:  Temp. 98.5, BP 126/72, P 72, regular RR 22.  Height 64 in., weight 149 lbs.  BMI 25.6 (Centers for Disease Control and Prevention, 2015).

HEENT:  Head:  Normocephalic, hair thick and evenly distributed throughout scalp.

Eyes:  Vision testing completed with old glasses.  Snellen chart 20/50 R, 20/40 L, and 20/30 both.  No ptosis.  No lesions noted.  Brows and lashes present.  L eye:  No erythema or exudate noted.  Sclera clear.  R eye:  Crusting noted on lashes with thick yellow mucous noted at medial canthus, which returns rapidly after cleaning.  Conjunctiva:  Red, PERRLA, EOMs intact.  Corneal light reflex symmetrical bilaterally.  Fundi:  Red reflex present bilaterally.  Discs flat with sharp margins.  Vessels present in all quadrants without crossing defects.  Retinal background has even color, no hemorrhages noted.  Macula has even color.

Ears:  Tympanic membranes gray and intact with light reflex noted.  Pinna and tragus non-tender. 

Nose:  Nares patent without exudate.

Throat:  Oropharynx moist, no lesions or exudate.  Tonsils ¼ bilaterally.  Teeth in good repair, no cavities noted.  Neck supple.  No lymphadenopathy.  Thyroid midline, small and firm without palpable masses.

Neck/Lymphatic:  Any trauma to neck?  Swelling or tenderness in areas of neck or around jaw?  Denies enlargement of lymph nodes.

Cardiovascular:  Heart S1 and S2 noted, no murmurs, noted.

Respiratory:   Lungs clear to auscultation bilaterally.  Respirations unlabored.

Abdominal:  Abdomen soft, non-tender, bowel sounds auscultated in all four quadrants fields.  No organomegaly noted.

Diagnostic:  Adenovirus rapid screening test negative.

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