NR511 Week 1 final SOAP (Note)
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Patient Information: M.S. 44, Female, Caucasian S: Subjective: Chief Complaint (CC): 44 year old female presents today with a complaint of “goop” in eye along with redness to eye after waking ... up this morning. HPI: Onset: 1 day Location: Eye Duration: 1 day Characteristics: Goop in eye with redness. Aggravating Factors: None reported Relieving Factors: None reported Treatment: None reported Current Medications: No prescribed medications. OTC medications include: Multivitamin daily, and B complex supplement Allergies: NKA PMHx: No chronic illness or injuries. No surgical history. Immunizations are up-to-date. Tetanus Booster unknown. Hospitalized for two childbirths. Soc Hx: High School graduate and is currently employed at a local business in the ordering department.Patient is married with four children. Patient has never smoked cigarettes, or any recreational substances. Patient states she is around second-hand smoke daily, but both her husband and her father smoke outside of the house. Patient also states she drinks socially. Patient states she sleeps 6-7 hours/night. Patient currently has 2 dogs and a cat. Patient states she and her husband enjoy traveling. Fam Hx: [Show More]
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