NR 511 Wk1 SOAP

NR 511 Wk1 SOAP

NR 511 Wk1 SOAP

Mary: MS, 44 year old female

Subjective:

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

HPI:

O: Started this morning.

L: Her eye.

D: Has been there since this morning.

C: Goop and redness.

A: Nothing makes the eye drainage worse.

R: Nothing makes the drainage better.

T: No treatments tried at home.

S: Did not go to work today because she didn’t want to infect her coworkers.

PMH: She denies any past illnesses or injuries or surgeries. She has been hospitalized twice for childbirth. She does not have any known allergies, only drinks alcohol socially, and denies tobacco or illicit drug use. She does not take any medications currently, but takes a daily multivitamin and a B complex supplement. She averages approximately 6-7 hours of sleep each night.

Family History: Both of her parents are alive. Her mother has a history of hypertension and hyperlipidemia. Her father has been using tobacco since age ten, and has a history of hypertension and hyperlipidemia. Mary’s two siblings are reported to be in good health.

Social History: Mary is married. She lives with her husband, both of her parents, and her four children. Her children consists of her daughter Mary Kate, ten-year-old son Michael, and four-year-old twins Paddy and Tommy. She also lives with her two dogs and a cat. Mary graduated from high school and works in the ordering department at a local business full time.

ROS:

Constitutional: Denies fever.

Head: No reports of headache

Eyes: No reports of changes in vision

Ears: Denies any ear pain, hearing loss, or ringing in the ears

Nose: Denies nasal congestion or discharge

Throat: Denies any difficulty swallowing or sore throat

Cardiovascular: Denies chest pain or palpitations

Respiratory: Denies cough, shortness of breath, or wheezing

Neurological: Denies headache or dizziness

Hematological/Lymphatic: Denies any enlarged lymph nodes

Objective:

VS:  height: 64 in, weight 149 pounds. BP 126/72, Temp 98.5, P 72, regular and RR 12.

BMI 25.6

General:

Assessment:

Plan: 

Patient Education: 

Follow-up: 

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References

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