Assignment 2.1 Topic Based SOAP Note NURS 621 S.O.A.P. Note Template

Assignment 2.1 Topic Based SOAP Note NURS 621 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