CONPH NSG6435 Subjective, Objective, Assessment, Plan (SOAP) Notes
Student Name: Course:
NSG6435
Patient Name: (Initials ONLY) M.P. Date: 04/18/2025 Time: 1400 PM
Ethnicity: African American Age: 2 Sex: Female
SUBJECTIVE (must complete this section)
CC : Per mother: “Pink eye has been going around her daycare. I noticed her left eye is red and watery.”
HPI: The patient is a 2-year-old African American female presenting in office with her mother with
complaints of possible pink eye from daycare. The patient’s mother reports the patient is having redness and
discharge from the left eye. The patient’s mother also reports that the symptoms have been ongoing for one to
two days and she has visualized the same symptoms spreading to the right eye as well. The patient’s mother
denies any other respiratory infection symptoms or fevers. Mother has not tried any over-the-counter
medications. Patient is eating and drinking normally. No other concerns voiced at this time.
Medications:
Albuterol sulfate 1.25 mg/3 mL solution for nebulization. Inhale 3 mL every 4-6 hours by inhalation route as
needed.
Previous Medical History: Asthma, Eczema
Developmental History:
Allergies: Claritin, mild reaction of hives all over body
Medication Intolerances: Claritin, mild reaction of hives all over body
Chronic Illnesses/Major traumas: Asthma, Eczema
Immunizations: Immunizations up to date. Refused COVID/FLU
Hospitalizations/Surgeries: No hospitalizations or surgery
Health Promotion/Health Maintenance
Nutrition/Diet: Nutrition: diet includes daily vegetables and fruits and dairy source: (Yogurt, cheese), Good
appetite, 3 meals/day, well balanced diet, including protein and iron-rich foods, appropriate Calcium intake,
fast food <1 time per week, eats meals as a family, and <8oz. sugar containing beverages daily.
Exercise/Regimen: Exercises every day, plays outside, limits TV/electronic use.
Tobacco/Alcohol/Vaping/Illicit Drug Use or Exposure: No passive exposure and no
smokers/drinkers/drug use in home
Safety Measures: Safety: no smokers in home/smokers around child, guns in home/homes where child
spends time, or concern for violence in home; has emergency numbers/poison control number near every
telephone and fire safety/escape plan; and smoke detectors on every floor, regularly tests alarms, CO detectors
on every floor, regularly tests alarms, always uses car seat in the back seat of car, uses helmet for riding a
tricycle or in a seat on and adult's bicycle, supervision at all times, including outside, safe practices around pool
& water, understanding of sun protection, understands insect repellant, and hot water temperature set at or
below 120F.
Screening exams: Parental concerns with child's hearing: No and speech: No. Concerns with child's vision:
No. Anemia Screening - based on risk assessment: Does child eat a vegetarian diet (does not eat red meat,
chicken, fish, or seafood)? No, child's diet includes iron-rich foods, such as meat, iron-fortified cereals, or
beans? Yes, and family struggle to put food on the table? No. Dyslipidemia Screening - based on risk
assessment: Dyslipidemia screen indicated: No. Tuberculosis Screening - based on risk assessment: Was child
or any household member born in, or has traveled to, a country where tuberculosis is common (Includes
countries in Africa, Asia, Latin America, Eastern Europe)? No, has child had close contact with a person who
has tuberculosis disease or who has had a positive tuberculosis test result? No, and Is child infected with HIV?
No.
FAMILY HISTORY (must complete this section)
M: 35 years of age. Alive and well. History of Pre-Hypertension
MGM: 60 years of age. Alive and well. History of Diabetes Mellitus Type 2
MGF: 61 years of age. Alive and well. History of Diabetes Mellitus Type 2
F: 36 years of age. Alive and well. No acute or chronic illnesses reported. No daily medications
PGM: 58 years of age. Alive and well. No acute or chronic illnesses reported. No daily medications
PGF: 62 years of age. Alive and well. No acute or chronic illnesses reported. No daily medications
Social History: Patient is a 2-year-old female who lives in a 4-bedroom home with both of her parents who
, are married. Patient is not exposed to any secondhand smoking. Parents do not smoke. Father does not drink
alcohol or do illegal drugs. Mother drinks wine socially but does not do any illegal drugs. Patient is enrolled in
daycare and attends 5 days a week.
REVIEW OF SYSTEMS (must complete this section)
General: Reported watery discharge and redness to left eye that Cardiovascular: Denies complaints of
has also spread to right eye. No report of fever or other chest pain
respiratory symptoms.
Skin: Denies any rashes or bruises. No report of trauma. Respiratory: Denies SOB or wheezing.
Eyes: Reported watery eye discharge and redness. No reports Gastrointestinal: Denies nausea,
of any vision problems or sensitivity. vomiting, or diarrhea
Ears: Denies ear discharge. Denies previous ear disorder or Genitourinary/Gynecological: Denies
drainage. urinary frequency urgency, or pain.
Nose/Mouth/Throat: Denies nasal drainage or congestion. Musculoskeletal: Denies joint swelling,
aches, or pain.
Breast: Denies pain or tenderness Neurological: Denies any loss of
consciousness. Denial of any weakness
Heme/Lymph/Endo: Denies abnormal bleeding or easy Psychiatric: Denies symptoms depression
bruising. or anxiety
OBJECTIVE (Document PERTINENT systems only, Minimum 3)
Weight: Height: BMI: BP: Temp: Pulse: Resp:18
33 lbs. 6 oz 3 ft. 2.5 in 15.8 88/58 98.3 101 SPO2%: 100%
General Appearance: Patient is alert and plays with toys in the room with mother. Patient responds when her
name is said. Patient able to communicate appropriately for her age. Mother can give accurate information on
patient. Patient is noted to be afebrile. Patient noted to rub left eye once or twice
Skin: No cyanosis noted. No bruising or injuries noted. Patient’s skin is warm to touch. No rashes or
abnormalities noted.
HEENT: Head is normocephalic and atraumatic. PERRLA. Tympanic membrane(s) pearly w/good landmarks.
Bilateral pinna well-formed. Nasal passages patent without crusts/sores. Tonsils with no erythema or exudate,
equal bilaterally and not enlarged. Normal mucous membranes with no lesions. No dental caries or plaque or
discoloration and teeth present and normal.
Cardiovascular: S1 and S2 sounds heard. No abnormal murmurs. No chest deformities. No edema. Capillary
refill <2 seconds on all four extremities
Respiratory: O2 saturation 100% on room air. No cough or wheezing noted. No wheezing upon auscultation.
Gastrointestinal: No abnormalities visualized. Normal bowel sounds. No tenderness upon palpation. No
hepatomegaly or splenomegaly noted
Breast: No lumps or lesions. No nipple discharge. No skin discoloration.
Genitourinary: Clear, straw-colored urine.
Musculoskeletal: Full range of motion noted without tenderness.
Neurological: Cranial nerves grossly intact.
Psychiatric: Patient engaged in conversation appropriate for age. Speech is understandable.
Diagnostic Studies: Bilateral eye examination done; no other diagnostic testing performed.
Special Tests: No special testing was performed.
112023 Page 1 of 2
CONPH NSG6435 Subjective, Objective, Assessment, Plan (SOAP) Notes
DIAGNOSIS (Minimum required differential and presumptive dx's, can do more)
Differential Diagnoses Diagnosis
• Diagnosis, (ICD 10 code and reference): H10.11 Allergic • Presumptive diagnosis (ICD 10 code and reference):
Conjunctivitis - H10.32: Unspecified acute conjunctivitis, left
• The symptoms of consistent with a differential eye
diagnosis of Allergic conjunctivitis due to eye - Symptoms that are consistent with this diagnosis that
drainage, red eyes, and possible itchiness (child noted this patient is experiencing are watery eye discharge,
to rub eyes erythematous eye mucosa, and being exposed during
Student Name: Course:
NSG6435
Patient Name: (Initials ONLY) M.P. Date: 04/18/2025 Time: 1400 PM
Ethnicity: African American Age: 2 Sex: Female
SUBJECTIVE (must complete this section)
CC : Per mother: “Pink eye has been going around her daycare. I noticed her left eye is red and watery.”
HPI: The patient is a 2-year-old African American female presenting in office with her mother with
complaints of possible pink eye from daycare. The patient’s mother reports the patient is having redness and
discharge from the left eye. The patient’s mother also reports that the symptoms have been ongoing for one to
two days and she has visualized the same symptoms spreading to the right eye as well. The patient’s mother
denies any other respiratory infection symptoms or fevers. Mother has not tried any over-the-counter
medications. Patient is eating and drinking normally. No other concerns voiced at this time.
Medications:
Albuterol sulfate 1.25 mg/3 mL solution for nebulization. Inhale 3 mL every 4-6 hours by inhalation route as
needed.
Previous Medical History: Asthma, Eczema
Developmental History:
Allergies: Claritin, mild reaction of hives all over body
Medication Intolerances: Claritin, mild reaction of hives all over body
Chronic Illnesses/Major traumas: Asthma, Eczema
Immunizations: Immunizations up to date. Refused COVID/FLU
Hospitalizations/Surgeries: No hospitalizations or surgery
Health Promotion/Health Maintenance
Nutrition/Diet: Nutrition: diet includes daily vegetables and fruits and dairy source: (Yogurt, cheese), Good
appetite, 3 meals/day, well balanced diet, including protein and iron-rich foods, appropriate Calcium intake,
fast food <1 time per week, eats meals as a family, and <8oz. sugar containing beverages daily.
Exercise/Regimen: Exercises every day, plays outside, limits TV/electronic use.
Tobacco/Alcohol/Vaping/Illicit Drug Use or Exposure: No passive exposure and no
smokers/drinkers/drug use in home
Safety Measures: Safety: no smokers in home/smokers around child, guns in home/homes where child
spends time, or concern for violence in home; has emergency numbers/poison control number near every
telephone and fire safety/escape plan; and smoke detectors on every floor, regularly tests alarms, CO detectors
on every floor, regularly tests alarms, always uses car seat in the back seat of car, uses helmet for riding a
tricycle or in a seat on and adult's bicycle, supervision at all times, including outside, safe practices around pool
& water, understanding of sun protection, understands insect repellant, and hot water temperature set at or
below 120F.
Screening exams: Parental concerns with child's hearing: No and speech: No. Concerns with child's vision:
No. Anemia Screening - based on risk assessment: Does child eat a vegetarian diet (does not eat red meat,
chicken, fish, or seafood)? No, child's diet includes iron-rich foods, such as meat, iron-fortified cereals, or
beans? Yes, and family struggle to put food on the table? No. Dyslipidemia Screening - based on risk
assessment: Dyslipidemia screen indicated: No. Tuberculosis Screening - based on risk assessment: Was child
or any household member born in, or has traveled to, a country where tuberculosis is common (Includes
countries in Africa, Asia, Latin America, Eastern Europe)? No, has child had close contact with a person who
has tuberculosis disease or who has had a positive tuberculosis test result? No, and Is child infected with HIV?
No.
FAMILY HISTORY (must complete this section)
M: 35 years of age. Alive and well. History of Pre-Hypertension
MGM: 60 years of age. Alive and well. History of Diabetes Mellitus Type 2
MGF: 61 years of age. Alive and well. History of Diabetes Mellitus Type 2
F: 36 years of age. Alive and well. No acute or chronic illnesses reported. No daily medications
PGM: 58 years of age. Alive and well. No acute or chronic illnesses reported. No daily medications
PGF: 62 years of age. Alive and well. No acute or chronic illnesses reported. No daily medications
Social History: Patient is a 2-year-old female who lives in a 4-bedroom home with both of her parents who
, are married. Patient is not exposed to any secondhand smoking. Parents do not smoke. Father does not drink
alcohol or do illegal drugs. Mother drinks wine socially but does not do any illegal drugs. Patient is enrolled in
daycare and attends 5 days a week.
REVIEW OF SYSTEMS (must complete this section)
General: Reported watery discharge and redness to left eye that Cardiovascular: Denies complaints of
has also spread to right eye. No report of fever or other chest pain
respiratory symptoms.
Skin: Denies any rashes or bruises. No report of trauma. Respiratory: Denies SOB or wheezing.
Eyes: Reported watery eye discharge and redness. No reports Gastrointestinal: Denies nausea,
of any vision problems or sensitivity. vomiting, or diarrhea
Ears: Denies ear discharge. Denies previous ear disorder or Genitourinary/Gynecological: Denies
drainage. urinary frequency urgency, or pain.
Nose/Mouth/Throat: Denies nasal drainage or congestion. Musculoskeletal: Denies joint swelling,
aches, or pain.
Breast: Denies pain or tenderness Neurological: Denies any loss of
consciousness. Denial of any weakness
Heme/Lymph/Endo: Denies abnormal bleeding or easy Psychiatric: Denies symptoms depression
bruising. or anxiety
OBJECTIVE (Document PERTINENT systems only, Minimum 3)
Weight: Height: BMI: BP: Temp: Pulse: Resp:18
33 lbs. 6 oz 3 ft. 2.5 in 15.8 88/58 98.3 101 SPO2%: 100%
General Appearance: Patient is alert and plays with toys in the room with mother. Patient responds when her
name is said. Patient able to communicate appropriately for her age. Mother can give accurate information on
patient. Patient is noted to be afebrile. Patient noted to rub left eye once or twice
Skin: No cyanosis noted. No bruising or injuries noted. Patient’s skin is warm to touch. No rashes or
abnormalities noted.
HEENT: Head is normocephalic and atraumatic. PERRLA. Tympanic membrane(s) pearly w/good landmarks.
Bilateral pinna well-formed. Nasal passages patent without crusts/sores. Tonsils with no erythema or exudate,
equal bilaterally and not enlarged. Normal mucous membranes with no lesions. No dental caries or plaque or
discoloration and teeth present and normal.
Cardiovascular: S1 and S2 sounds heard. No abnormal murmurs. No chest deformities. No edema. Capillary
refill <2 seconds on all four extremities
Respiratory: O2 saturation 100% on room air. No cough or wheezing noted. No wheezing upon auscultation.
Gastrointestinal: No abnormalities visualized. Normal bowel sounds. No tenderness upon palpation. No
hepatomegaly or splenomegaly noted
Breast: No lumps or lesions. No nipple discharge. No skin discoloration.
Genitourinary: Clear, straw-colored urine.
Musculoskeletal: Full range of motion noted without tenderness.
Neurological: Cranial nerves grossly intact.
Psychiatric: Patient engaged in conversation appropriate for age. Speech is understandable.
Diagnostic Studies: Bilateral eye examination done; no other diagnostic testing performed.
Special Tests: No special testing was performed.
112023 Page 1 of 2
CONPH NSG6435 Subjective, Objective, Assessment, Plan (SOAP) Notes
DIAGNOSIS (Minimum required differential and presumptive dx's, can do more)
Differential Diagnoses Diagnosis
• Diagnosis, (ICD 10 code and reference): H10.11 Allergic • Presumptive diagnosis (ICD 10 code and reference):
Conjunctivitis - H10.32: Unspecified acute conjunctivitis, left
• The symptoms of consistent with a differential eye
diagnosis of Allergic conjunctivitis due to eye - Symptoms that are consistent with this diagnosis that
drainage, red eyes, and possible itchiness (child noted this patient is experiencing are watery eye discharge,
to rub eyes erythematous eye mucosa, and being exposed during
