NR511 Elog Soap Wk4

NR511 Elog Soap Wk4

NR511 Elog Soap Wk4

SOAP Note 4

Patient Information:

P.B. 51, Male, Caucasian, Commercial Insurance

S: Subjective:

Chief Complaint (CC): 51 year old male presents today with a complaint of “tearing and sensitivity to light” in right eye.  Patient also c/o redness to right eye.

HPI:

Onset: 2 days

Location: Right Eye

Duration: 2 day

Characteristics: Tearing, redness and sensitive to light. 

Aggravating Factors: Light

Relieving Factors: None reported

Treatment: None reported

Current Medications: No prescribed medications.  No OTC medications or herbal supplements.

Allergies: NKA

PMHx:

No chronic illness or injuries. No surgical history. Immunizations are up-to-date. Tetanus Booster unknown.

NR511 Elog Soap Wk4

Soc Hx:

Master graduate and is currently employed at the Space Center as an engineer.  

Patient is married with four children. 

Patient has never smoked cigarettes, or any recreational substances. 

Patient states he enjoys traveling. 

Fam Hx:

Mother (85 years old) and father (86years old) currently live nearby.  Mother hx of hypertension and hyperlipidemia. Father with hx of hyperlipidemia, hypertension.  One brother (48 years old) with no medical problems.

All children are alive with no medical conditions to his knowledge.

Review of Symptoms (ROS):

CONSTITUTIONAL:  No weight loss, fever, chills, weakness or fatigue.

HEENT:  Head – no headache, dizziness, or syncope. Eyes:  + (clear watery discharge with redness in right eye).  Ears – no hearing loss, no ear discharge, or swelling.  Nose – no sneezing, congestion, or runny nose.

CARDIOVASCULAR:  No chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  No shortness of breath, cough or sputum.

ALLERGIES:  NKDA

O: Objective Data

Temperature: 98.5 oral, Pulse 78, R 16, BP 134/74, O2 100%, Height 5’9”, Weight 169lbs. BMI: 25.0 (Normal).

Physical exam:

GENERAL APPEARANCE: Well groomed, well nourished, alert and cooperative, and appears to be in no apparent distress. Appropriately dressed male.

HEENT: Head- Normocephalic, atraumatic, symmetric, non-tender, normal inspection. Eyes: Left eye: no erythema or exudate noted. Sclera is clear.  Right eye: thin clear watery discharge.  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.   Visual acuity and extraocular eye movements intact. No nystagmus noted. Ears: Bilateral canals patent without erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Nose: Bilateral nares intact.  No deviation or perforated septum.  No transverse nasal crease noted. Throat: uvula midline. No erythema, swelling, exudate, or lesion noted.  Teeth and gingiva in good general condition.

NECK/LYMPHATICS:  Supple, non-tender.  Trachea midline, no swelling. No cervical, submental, post-auricular, or supraclavicular lymphadenopathy noted. No thyroid nodule or thyromegaly. No palpable masses.

RESPIRATORY/CHEST: No resp. distress. No use of accessory muscles.  Lungs resonant upon percussion.  Breath sounds normal to auscultation, no adventitious sounds noted.  Thorax symmetric, with symmetric expansion.

CVS: No murmurs, rubs, or gallops.  S1 and S2 normal.  Rhythm is regular.  There is no peripheral edema, cyanosis or pallor.  Extremities are warm and well perfused.  Capillary refill is less than 3 seconds.  No carotid bruits.

A: Assessment:

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