WEEK 1 PART 2 1
CASE STUDY I SOAP NOTE
Mary 44 year old female, Caucasian
S: Subjective
Chief Complaint (CC): “My right eye is red and was full of goop this morning”
History of present illness (HPI):
O: Mary awoke this morning with her right eye red with “goop” in it
L: right eye
D: right eye drainage and reddening continues since this morning
C: includes left eye red and has goopy drainage present upon awaking this morning
A: no information provided.
R: no information provided
T: No treatment
PMI:
Denies past illness or injuries. Hospitalized x 2 for childbirth, no surgeries.
No information given for Immunizations
Drinks alcohol socially, denies tobacco or illicit drug use.
Sleeps 6-7 hours/night.
NKDA
No current prescription medications. Takes a daily multivitamin and a B complex supplement.
Social
Mary is a high school graduate and works full time at a local business in the ordering department
Family
Mary lives at home with Patrick her husband and her three biological children 4 year old
fraternal twin sons in preschool, daughter 7 2cd grade, and her son through marriage age 10.
Mary’s parents Katie and John live in the home they are retired and assist with child care and
house hold, Mary has 2 siblings who are in good health. Patrick is an only child whose parents
died of old age in their 70s. Mary’s mother has a history of HTN and hyperlipidemia. Father
John HTN and hyperlipidemia and uses tobacco since age 10. Patrick and John both smoke “but
not in the house”. There are 2 dogs and a cat that live in the house.
Review of Systems (ROS).
, WEEK 1 PART 2 2
Constitutional: Denies fever or chills
Eyes: Denies visual loss or changes in either eye, denies pain denies redness or drainage of left
eye, reports redness and drainage of right eye
Ears, Nose, Mouth, Throat: Denies nasal drainage, sneezing, congestion, denies pain, loss of
hearing or ringing in ears bilateral, Denies pain with swallowing, denies neck or throat swelling
or warmth
Cardiovascular: Denies chest pain, palpitations, pressure
Pulmonary: Denies Shortness of breath with exertion, difficulty breathing
Lymphatic: Denies swelling of throat or neck, or under arms
O: Objective:
PE: Physical exam
VS: Ht. 64 in, Wt.149 pounds. BMI 25.6, BP 126/72, Temp 98.5, P 72, regular and RR 12.1
Constitutional: Woman Caucasian, 44 years old looks younger for age, Alert and oriented
compliant with examination and appropriate with speech and word choice in no apparent distress
sitting calmly with daughter at side , dressed appropriately for season, nails and hair clean and
neat,
Head: Normocephalic head with evenly thick distributed hair attached firmly to scalp.
Eyes: Visual acuity tested with patient wearing old pair corrective glasses patient usually wears
contact lenses Snellen: R: 20/50 L: 20/40 and 20/30 bilateral. No ptosis noted, Eyes with no
lesions or scarring noted, brows and lashes present and symmetrical Left eye: no erythema or
exudates noted, sclera clear. Right eye with crusting on lashes, thick yellow mucous present at
medial canthus which reaccumulates immediately upon clearing. Conjunctiva red, PERRLA,
EOMs intact. No corneal abrasion or involvement noted corneal light reflex symmetrical
bilaterally. No ptosis. No lesions noted. Brows and lashes present. Left eye: no erythema or
exudate noted. Sclera clear. Right 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 nontender
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.
CASE STUDY I SOAP NOTE
Mary 44 year old female, Caucasian
S: Subjective
Chief Complaint (CC): “My right eye is red and was full of goop this morning”
History of present illness (HPI):
O: Mary awoke this morning with her right eye red with “goop” in it
L: right eye
D: right eye drainage and reddening continues since this morning
C: includes left eye red and has goopy drainage present upon awaking this morning
A: no information provided.
R: no information provided
T: No treatment
PMI:
Denies past illness or injuries. Hospitalized x 2 for childbirth, no surgeries.
No information given for Immunizations
Drinks alcohol socially, denies tobacco or illicit drug use.
Sleeps 6-7 hours/night.
NKDA
No current prescription medications. Takes a daily multivitamin and a B complex supplement.
Social
Mary is a high school graduate and works full time at a local business in the ordering department
Family
Mary lives at home with Patrick her husband and her three biological children 4 year old
fraternal twin sons in preschool, daughter 7 2cd grade, and her son through marriage age 10.
Mary’s parents Katie and John live in the home they are retired and assist with child care and
house hold, Mary has 2 siblings who are in good health. Patrick is an only child whose parents
died of old age in their 70s. Mary’s mother has a history of HTN and hyperlipidemia. Father
John HTN and hyperlipidemia and uses tobacco since age 10. Patrick and John both smoke “but
not in the house”. There are 2 dogs and a cat that live in the house.
Review of Systems (ROS).
, WEEK 1 PART 2 2
Constitutional: Denies fever or chills
Eyes: Denies visual loss or changes in either eye, denies pain denies redness or drainage of left
eye, reports redness and drainage of right eye
Ears, Nose, Mouth, Throat: Denies nasal drainage, sneezing, congestion, denies pain, loss of
hearing or ringing in ears bilateral, Denies pain with swallowing, denies neck or throat swelling
or warmth
Cardiovascular: Denies chest pain, palpitations, pressure
Pulmonary: Denies Shortness of breath with exertion, difficulty breathing
Lymphatic: Denies swelling of throat or neck, or under arms
O: Objective:
PE: Physical exam
VS: Ht. 64 in, Wt.149 pounds. BMI 25.6, BP 126/72, Temp 98.5, P 72, regular and RR 12.1
Constitutional: Woman Caucasian, 44 years old looks younger for age, Alert and oriented
compliant with examination and appropriate with speech and word choice in no apparent distress
sitting calmly with daughter at side , dressed appropriately for season, nails and hair clean and
neat,
Head: Normocephalic head with evenly thick distributed hair attached firmly to scalp.
Eyes: Visual acuity tested with patient wearing old pair corrective glasses patient usually wears
contact lenses Snellen: R: 20/50 L: 20/40 and 20/30 bilateral. No ptosis noted, Eyes with no
lesions or scarring noted, brows and lashes present and symmetrical Left eye: no erythema or
exudates noted, sclera clear. Right eye with crusting on lashes, thick yellow mucous present at
medial canthus which reaccumulates immediately upon clearing. Conjunctiva red, PERRLA,
EOMs intact. No corneal abrasion or involvement noted corneal light reflex symmetrical
bilaterally. No ptosis. No lesions noted. Brows and lashes present. Left eye: no erythema or
exudate noted. Sclera clear. Right 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 nontender
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.
