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EENT SOAP Note
ID: L.D., 26-year-old Asian female born on May, 1, 1997, arrived at the clinic unaccompanied. She is single and was able to provide thorough medical history. She has insurance coverage under Lakeside/IPA.
Subjective
CC: “I’m here to get my left eye checked and see if I can get some prescription eyedrops for it.”
HPI: L.D., a 26-year-old Asian female, arrived at the clinic as walk-in patient, expressing concerns about the redness and yellow-greenish discharge in her left eye that began two days ago. She reported that initially, she thought her left eye was just itchy and watery while she was watching TV, but when she woke up this morning, she noticed redness, swelling and crusty discharge on her left eye. She denies experiencing any pain but reports feeling irritation in left eye. Patient denies use of contact lenses or any trauma, injury, or exposure to foreign objects. Patient reported that she hasn’t used any over-the-counter eyedrops or tried any home remedies because she wants to have it checked to obtain prescription eye drops. Patient denies any bleeding on the eye, changes in vison or photophobia. She also denies any other accompanied symptoms such as fever, cough, congestion, or sore throat.
Past Medical History
Medical:
Denies prior medical condition or childhood hospitalization.
Surgery:
None.
Allergies:
No known allergies to food, drug, environmental factors.
Medications:
OTC Multivitamins 1 tab PO Daily
Vaccinations:
Current with all childhood immunizations.
4 series COVID vaccines
Declines Flu Vaccine
Family History:
MGF/MGM: deceased, unknown history
PGM: deceased at age 60s, hypertension, DM, hyperlipidemia, stroke
PGF: alive, age 88, hypertension, COPD
Mother: alive, age 61, hypertension
Father: alive, age 60, arthritis, DM
3 siblings: healthy
Social History:
Occupation:
Works as a manager in a fast food.
Stress:
Chemical:
Review of Systems
Constitutional:
Head:
Eyes:
Ears, Nose, Mouth/Throat:
CV:
Pulmonary:
GI:
GU:
Musculoskeletal:
Integumentary:
Neurological:
Psych:
Hematologic/Lymphatic:
Endocrine:
Objective
Vital Signs:
T: 97.9 P: 83 R: 20 BP: 111/76 SPO2: 98% RA
Pain: 0/10 Height: 5’3” Weight: 118lbs BMI: 20.9
Physical Exam:
General:
Head:
Eyes:
Ears:
Mouth/Throat:
Neck:
CV:
Pulmonary:
GI:
GU:
Musculoskeletal:
Neuro:
Assessment
Plan
