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Assignment 2.1 Topic Based SOAP Note-2023.
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Assignment 2.1 Topic Based SOAP NoteNURS 621
Patricia Howard-Chittams
S.O.A.P. Note Template
Case ID#: 0001
Subjective
Objective
Assessment (diagnosis [primary and differential diagnosis])
Plan (treatment, education, and follow up plan)
Basic Information
Patient demographics.
Smith, Samuel (preferred name: Sam) DOB: 05/09/1977 Insurance: AmeriHealth
Co-Pay: $10.00
Subjective History
Chief Complaint
What brought you here today…The patient reports a history of right eye tearing and
irritation for one day.
History of Present Illness
42-year-old male complains of right eye irritation, redness and tearing x 1 day. “I wear
contacts and it felt like I got something in it yesterday while doing yard work”. Pt. states
he removed his contacts, and soaked the soft contacts in Onset solution and put them
back in the next day. Pt. states he flushed his eye with saline solution when he removed
the contacts. Pt. denies use of anything else in his eye. Pt. complains of gritty feeling
in only the right eye and photophobia. Pt. rates eye pain 7/10. Pt. reports closing his
eye makes it feel better and using warm compresses helps it to feel better also. The Pt.
reports that the pain then reduces to a 4/10. Pt. said that he used OTC ibuprophen to
reduce pain. Pt. denies floaters, or flashes of light. Pt. states that the eye “feels like the
eye is gritty”, but denies sharp pain. Pt. denies headache, dizziness, neck pain, head or
neck surgeries. Denies tramautic blows to the head or eyes. Admits to not wearing
appropriate eye protection while working in the yard.
This study source was downloaded by 100000829421030 from CourseHero.com on 07-11-2022 08:15:59 GMT -05:00
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, Assignment 2.1 Topic Based SOAP Note
NURS 621
Patricia Howard-Chittams
Past Medical History
Adult Illnesses, childhood illnesses, immunizations, surgeries, allergies, current
medications
Pt. denies that he has had issues with his eyes before. Pt. admits to not wearing
protective glasses while working in the yard.
Childhood Diseases: Positive for varicella at age 8. Pt. denies any other childhood
diseases.
Immunizations: Pt. received flu shot on 12/2/2019. Up to date on all other
immunizations notes that he should have his TdaP immunization in June of 2020.
Surgeries: Pt. denies any surgeries.
Allergies: Pt. admits seasonal allergies, denies medication or food allergies.
Current Medication: hydrochlorothiazide one 25 MG Tablet per day for hypertension;
Zyrtec 10 mg and Flonase mcg 2 sprays as needed for seasonal allergies.
Psychiatric: Pt. denies depression, anxiety, and has no thoughts of suicide. States his
outlook on life is “relatively positive”.
Past Hospitalizations: Pt. denies past hospitalizations.
Family History
Include parents, siblings; grandparents if applicable/known, cause of death, age,
pertinent medical illnesses
Mother: Aged 86 history of hypertension, diabetes type 2, and sleep apnea.
Father: Deceased age 78, history of hypertension, diabetes type 2
Brother: No medical history
Maternal Grandfather: Deceased aged 90 – no known health history
Maternal Grandmother: Deceased – No known health history
Paternal Grandmother: Deceased Aged 65 – died of a “heart attack”
Paternal Grandfather: Deceased Aged 35 – Vietnam – Combat injuries
Personal/Social History
Education, marital status, occupation, alcohol/drug use, smoking status, sexual history
if relevant, exercise, nutrition, religious preference if known
Education: College educated – Accounts Payable
Married: 20 years
Sexual History: Hetrosexual – monogamous relationship for 25 years.
Exercise: Rarely – working in the yard, walking the dog about 20 minutes two or three
evenings per week.
Smoking Status: Non-smoker
This study source was downloaded by 100000829421030 from CourseHero.com on 07-11-2022 08:15:59 GMT -05:00
https://www.coursehero.com/file/62316612/Assignment-21-Topic-Based-SOAP-Notedocx/
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