Using the condition you posted about in DQ 1 this week, provide a SOAP note using the format outlined below. Support your summary and recommendations plan with a minimum of two APRN-approved scholarly resources. You may not select a condition or disorder that has already been profiled by another learner; you must select a different one.

Using the condition you posted about in DQ 1 this week, provide a SOAP note using the format outlined below. Support your summary and recommendations plan with a minimum of two APRN-approved scholarly resources. You may not select a condition or disorder that has already been profiled by another learner; you must select a different one.

Using the condition you posted about in DQ 1 this week, provide a SOAP note using the format outlined below. Support your summary and recommendations plan with a minimum of two APRN-approved scholarly resources. You may not select a condition or disorder that has already been profiled by another learner; you must select a different one.

­­­­SOAP Note 

Subjective

Patient:  JA, 31 years, Female

Chief Complaint: “My eyes are teary”.

History of Present Illness:  JA, a 31-year-old female, presents to the clinic with complaints of blurry and teary eyes that started in the evening eye. She had just been well then; she noted it was slowly getting difficult to work from the laptop, as the eyes were getting blurry. She reports feeling something in the eye, giving her the urge to rub. She has not taken anything for the eye and reports no pain.

BUY A CUSTOM PAPER HERE

Past Medical History:  N/A

Past Surgical History:  N/A

Medications:  No medications

Allergies: No allergy reported  

Immunizations:  Tdap 23/8/2021, pneumonia 4/11/2021, shingles 12/10/2020, influenza 11/9/2021, COVID 4/3/2021

Family History:  Single mother who lives in a townhouse with her 7-year-old son. She is employed with a good income and has health insurance.

Social History/Risk Factors: Report no use of tobacco, alcohol, or substances

Review of Systems:

General: (-) fevers, (-) chills, (-) unintentional weight loss/gain or changes in appetite, (-) changes in exercise ability, (-) fatigue.

Head: (-) headache, (-) dizziness, (-) sinus pressure (frontal and maxillary).

Eyes: (+) changes in vision, (+) blurred vision, (-) double vision, (-) floaters. Last eye exam: (+) redness, (-) drainage (+) watery eyes.

Ears: (-) changes or difficulty in hearing, (-) ear pain, (-) drainage.

Nose: (-) difficulty smelling, (-) runny nose, (-) congestion, (-) epistaxis

Mouth/Throat: (-) problems swallowing, (-) difficulty eating/chewing foods, (-) sores or lesions, (+) postnasal drip. Last dental exam:

Neck: (-) stiffness, (-) pain, (-) left neck nodule, (-) reflux.

Respiratory: (-) difficulty breathing, (-) shortness of breath, (-) cough (-) dyspnea, (-) wheezing.

Cardiovascular: (-) chest pain, (-) abnormal heart beats, (-) skipped beats, (-) fluttering, (-) shortness of breath with exertion.

GI: (-) nausea/vomiting, (-) heartburn, (-) acid reflux, (-) pain with defecation, (-) rectal bleeding, (-) hemorrhoids. Bowel movement. (-) constipation, (-) diarrhea.

GU: (-) difficult urination, (-) painful urination, (-) urinary frequency.

GYN: (if applicable) (-) abnormal menstrual bleeding, (-) vaginal discharge/odor, last menstrual period (LMP).

Musculoskeletal: (-) painful bilateral legs, (-) pain joints, (-) problems with range of motion, (-) stiffness, (-) backaches.

Neurological: (-) weakness, (-) dizziness, (+) blurred vision, (-) unsteady gait, (-) changes in memory, (-) changes in mood.

 

Psychiatric: (-) depression, (-) anxiety, (-) sleep disturbances, (-) nervousness, (-) suicidal ideation, (-) suicidal attempts.

Skin: (-) changes in skin, (-) rashes, (-) lesions.

Endocrine: (-) weight loss or weight gain, (-) excessive sweating, (-) hair thinning/loss, (-) hot or cold intolerance, (-) excessive thirst.

Hem/Lymph: (-) bruising or getting sick easily, (-) excessive healing time, (-) anemia.

Objective

Vital Signs: 

Temp 37 ^o C, BP 89/126, Pulse 98, Respiratory Rate 12, Height 4 5”, Weight 65kg.

General: Alert and oriented to time and place, appropriately dressed for the weather. Affect is good.

Neurological: no dizziness, seizure, or syncope

HEENT: blurred vision, red-eye. No hearing loss

Neck: no neck pain

Lymph Nodes:

Respiratory: no difficulties in breathing

Cardiovascular: no chest pain or pressure, S3 and S4 murmur

GI: no vomiting, diarrhea, nausea, or abdominal pain. All four quadrants non-tender to palpation.

Back: no back pain

Musculoskeletal: no pain or swelling to the extremities. Normal ROM

Skin: no rashes or inflammation

Psychiatric: Mood and affect good

Assessment

Lab Tests

Observing the eye under a high beam of light and microscope – will reveal the red/pink coloration of the white part of the eyeball, indicating a sign of inflammation (Bickley et al., 2020)

Working diagnosis

Conjunctivitis ICD-10 code: H10

The rationale for primary diagnosis is supported by reported symptoms, examination, and assessment results.

Differential diagnosis

1. Blepharitis
2. Corneal abrasion
3. Glaucoma

Problem list

1. Elevated blood pressure

Plan

Diagnostic tests

• Visual acuity test – check the extent of the damage by knowing if the patient can read small fonts at a distance (Chen et al., 2020)
• Eye culture – will evaluate whether the causative agent is bacteria or virus

Pharmacology

• Not necessary unless the condition persists or worsens

Non-pharmacology treatment

• Artificial tears and cold compresses to relieve the dryness and inflammation (Yeu et al., 2020)

Patient education

• Avoid rubbing the eyes because it worsens the condition
• Wash hands thoroughly
• Do not share personal items such as make-up, contact lenses, towels, bedding, and eyeglasses.
• Encourage physical activity and healthy eating

Referral

• Refer to a cardiologist for further investigation of blood pressure to know whether the patient is hypertensive

Follow-up plan

• Follow-up after one week, if the condition persists, the patient will be given ointment or antibiotic drops depending on the outcome of the culture test.

References

Bickley, L. S., Szilagyi, P., Hoffman, R., & Soriano, R. (2020). Bates’ Guide To Physical Examination and History Taking (Lippincott Connect) 13th Edition. LWW.

 Chen, L., Deng, C., Chen, X., Zhang, X., Chen, B., Yu, H., . . . Sun, X. (2020). Ocular manifestations and clinical characteristics of 535 cases of COVID-19 in Wuhan, China: a cross-sectional study. Acta Ophthalmol, 98(8), e951-e959. https://doi.10.1111/aos.14472

Yeu, E., & Hauswirth, S. (2020). A Review of the Differential Diagnosis of Acute Infectious Conjunctivitis: Implications for Treatment and Management. Clin Ophthalmol, 14, 805–813. https://doi.10.2147/OPTH.S236571.

ORDER A PLAGIARISM-FREE PAPER HERE

Assessment Description
Using the condition you posted about in DQ 1 this week, provide a SOAP note using the format outlined below. Support your summary and recommendations plan with a minimum of two APRN-approved scholarly resources. You may not select a condition or disorder that has already been profiled by another learner; you must select a different one.

Subjective

CC (Chief complaint)
HPT (History of present illness)
History (Pertinent medical, surgical, social, medications, exposure, family history, allergies, vaccines)
ROS (Review of systems)
Objective

Vital signs/BMI
Physical exam findings
Diagnostic results (include actual “results” or “findings” that you would expect for a certain scenario)
Assessment/Plan

Differential list and rationale for final/working diagnosis
Problem list
Plan for Each Problem

Based on evidence with proper references
Further diagnostic testing you would order
Nonpharmacologic therapy
Pharmacologic therapy, including specific medication dose
Frequency and duration of therapy
Patient education
Follow-up