Episodic SOAP
Provide information: Episodic SOAP note #4, Spring 2022
Date of patient encounter: 01/28/2022
Patient age and gender: 47-year-old, male Hispanic
DOB: 10/21/1975
SUBJECTIVE:
Chief Complaint: "My eyes are itching, red and watery, and my eyelids stuck together in the
morning”
History of Present Illness: 47-year-old male Hispanic presents with complaints of watery
discharge in both eyes (location) for the last 6 days (chronology). Symptoms began six days ago
with not improvement in both eyes after riding his motorbike on a long road trip and wearing
contact lenses. (location/setting). The patient states that touching the site or laying on his face
while sleeping aggravates the pain, (aggravating factor). He has been taking ibuprofen and
Refresh eyedrops with a little relief, and cool compresses a few times a day (alleviating factors).
The patient also has a periorbital erythema, red conjunctive, itching during day and night, and his
eyelids are stuck together every morning (associated manifestations).
Past Medical History:
A. Past Medical History: Nicotine dependence, F17.210
Denies any history of asthma, CVA, hypertension, cholesterol, seizures, aortic
aneurism, myocardial infarction, cancer, migraine, tuberculosis, HIV, GU conditions.
B. Surgery History: Denies any surgical procedure
C. Hospitalizations: Denies any hospitalization in the past.
D. Childhood illnesses: He cannot recall any childhood illnesses.
Current Health Status
A. Allergies: NKDA
B. Social History (alcohol, drug or tobacco use):
i. Tobacco: Smoker for 10 years, 4-5 cigarettes per day;
ii. Alcohol: Socially, 2-3 beers every weekend.
iii. Illegal drugs: Smoked Marijuana for a year on his 20’s. Denies
any use of cocaine, stimulants, mushrooms or other substances.
C. Current medications: No current prescriptions or OTC medications.
D. Injuries: Denied any injuries
E. Environmental Hazard: Riding a motorbike with his friends, driving to work.
No hazards at home.
F. Screening Testing:
Dental: July 2021, all between normal parameters.
Visual: July 2021, all between normal parameters
Hearing: Never
Colonoscopy: Never
Testicular exam: Every 6 months when he remembers
Lipid Profile: 6 months ago (He recalls that LDL was a bit elevated, and other
bloodwork was normal on his annual physical exam). Physician recommended
diet and exercise.
G. Safety measures employed on a regular bases: Patient works in Real state,
driving mostly all day, Seatbelt in the car, Helmet in the bike
H. Immunizations: COVID 19 Vaccine J&J: January 2021
Booster: Pfizer, December 2021
Flu shot: Never taken
Others: He can’t recall the exact day or name of other vaccines.
I. Health Maintenance: Dental and visual last year, both reported normal. Uses
contact lenses to change his eye color.
J. Exercise & Leisure: He enjoy riding his motorbike with friends during the
weekend. Stated that exercises about 2 times per week. Patient does not have
children and enjoys spending time with his wife.
K. Sleep: 8 hours every day from 11pm till 7 am. No naps during the day. States
having trouble falling asleep related to his eye itchiness, denied any snoring,
shortness of breath, insomnia or sleep apnea.
Diet: 24 hour recall
Breakfast 01/27/2022: Eggs with wheat toast, and coffee
Lunch 01/27/2022: Chicken sandwich with water to drink
Dinner 01/27/2022: Green salad with chicken and ice tea.
Breakfast 01/28/2022: Egg white with sausage, 2 pieces of toast, and black coffee
M. Family History:
Mother: alive 72 years old, Osteoporosis
Father: Died 62, Hypertension and diabetes
Brother: 37, Obesity
Paternal Grandmother: died (72 y/o) unknown cause
Maternal Grandmother: died (65 y/o) Breast Cancer
Paternal Grandfather: died (83 y/o) unknown cause
Maternal Grandfather: died (62y/o) unknown cause
N. Social History:
Marital Status: Married, lives with his wife
Dependents: 0
Work: Own a real estate company.
Sexual History: Active, one partner, no of STI’s history or concerns.
# Lifetime partners: Denied to answer
Sexual protection/contraception: His wife uses IUD.
IV drug use: Denies use of any IV substance
Review of Systems:
 General: Denies any unintentional weight loss. Denies weight gain, fatigue, chills, or
weakness. Denies having any unexplained bruising or bleeding.
 Skin, Hair, and Nails: Skin dry and warm to touch. Hair appears clean and strong. No
breakage in hair. Nails are strong and no clubbing is noted.
 Chest and Lungs: Denies shortness of breath, coughing, emphysema, bronchitis, sputum,
dyspnea. Denies any hemoptysis, night sweats, or exposure to tuberculosis, no current xray
 Cardiovascular: No murmurs, angina, palpitations, orthopnea, or edema. Denies dyspnea
on exertion. Capillary refill <3 bilaterally on upper and lower extremities. Pulses present
radial 2+ and pedal 2+ No pitting edema in any extremities.
 Musculoskeletal: Patient denies pain or weakness. Patient denies range of motion issues
or gout. Normal ROM, denies back pain or other joint pain. Denies history of arthritis
 Peripheral Vasculature: Denies leg cramps or swelling; current blood clots; no
complaints of leg cramps or varicose veins, denies hand discoloration, fingertips or toes.
 Lymphatic: No known lymph node tenderness or enlargement reported.
 Gastrointestinal: Denies nausea, vomiting, dysphagia, hemorrhoids, hematemesis,
constipation, jaundice, or hepatitis. No masses upon assessment. Denies changes in
appetite. Denies blood in stool or any changes in stool color. No diarrhea.
 Neurologic: Denies weakness, numbing, loss of sensation, tingling, syncope, tremors,
seizures, denies syncope or fainting or loss of consciousness.
 Mental Status and Psychiatric: Patient is anxious due to eye itchiness, denies depression
any sleep disturbances, or memory problems.
II. Objective Data
A. General Appearance Statement:
47-year-old male Hispanic well-nourished and well developed for his age, alert, oriented x 3 with
an appropriate speech, well dressed, hearing appears intact responding appropriately to
questions, not in distress who appears fatigue. Patient is pleasant, cooperative and calm. Admits
being anxious day and night with the feeling on his eyes.
B. Vital Signs:
 BP: 120/82 mm/hg on right arm sitting, adult size cuff.
 RR: 18
 HR: 82
 T: 98.8 F, in Forehead
 Ht: 5 ft 8 in
 Wt: 151 lb
 BMI: 22.3 Patient’s BMI is normal
 O2 Sat: 99% at Room Air
Physical Exam:
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Skin, Hair, and Nails: Dry and warm to touch, no rashes or lesions. Hair is black and
strong with normal thickness. Nail beds are pink without clubbing. Nails are uniform in
thickness, smooth, < 3 second capillary refill in all extremities.
HEENT: Head is normal size, round, erect in midline. Facial features and expressions are
symmetrical when talking (CN VII), smile is symmetrical, (CN V), and lips are
symmetrical when speaking (CN VII). Conjunctive is red, and swollen, purulent
discharge present, yellow crust on eyelids, CN II, III, IV, VI intact. PERRLA with Pupils
round, size 3 mm bilaterally. Tympanic membranes are clear, flat and gray in color. No
hearing loss, repeated whispered words bilaterally, CN VIII intact. Nasal mucosa is clear,
no drainage, able to identify smells, CN I intact. Uvula midline, pink, raises when say
“A”, cranial nerve IX, X, and XII intact. Carotid pulse palpable 3+ bilaterally. Trachea
midline. ROM of neck and shoulders without pain or difficult (CNXI).
Chest and Lungs: Clear, diminished bilateral lung sounds. no evidence of wheezing or
uses of accessories muscles, no retractions.
Chest rises symmetrically, easily and evenly with respirations. No distress or labored
breathing. Denies chest pain.
Cardiovascular: S1 and S2 heard. Normal heart rate. No gallops, rubs, clicks, or
murmurs. Capillary refill <3 bilaterally on upper and lower extremities. Pulses present
radial 2+ and pedal 2+ LLE non-pitting edema noted, No pitting edema in any
extremities.
Gastrointestinal: Abdomen is rounded, soft, and symmetrical. Hyperactive bowel sounds
in all quadrants. Umbilicus is midline. No rashes, masses. Abdomen is soft with slight
tenderness upon palpation in surgical areas. No ascites noted. Liver not palpable. Spleen
not palpable.
Musculoskeletal: No weakness, full ROM in all joints. Normal strength in all other
extremities. No decreased muscle strength when opposing force applied to ROM.
Flexion and extension maintained against resistance. Normal spinal curvature. Babinski
reflex negative.
Lymphatic: No palpable lymph nodes.
Neurologic: Awake alert and oriented x3, Patient able to follow directions, speech is
clear, with no attention or concentration deficit. Short- and long-term memory intact.
Deep tendon reflexes 2+, No tremors or weakness, gait within normal limits. Negative
Romberg, positively differentiate dull and sharp sensations, positive Graphesthesia test,
and Cranial Nerves I to XII intact
Present labs/diagnostic tests:
 Eye culture and Gram Stain: Results pending
III. Assessment
Problem Statement:
47-year-old male Hispanic with an onset of watery discharge in both eyes, sometimes purulent,
with itching, erythematous swollen conjunctiva, and yellow crust on eyelashes for the past 6
days. Assessment elicits a Bacterial Conjunctivitis.
Differential Diagnosis:
1. Bacterial conjunctivitis ICD code: H10.33
2. Uveitis ICD code: H43.89
3. Acute viral conjunctivitis, ICD code: B30.90
Final Diagnosis:
1. Bacterial conjunctivitis ICD code: H10.33
Final diagnosis supported by symptoms, patient history and physical assessment. Patient reports
itching, irritated red eyes with a watery or purulent discharge for the last 6 days. Conjunctivitis is
the inflammation of the lining of the eyelids and eyeball caused by bacteria, viruses, allergic or
immunologic reactions, mechanical irritation with itching, and discharge as a predominant
symptom (Bhanot, S., & Sharma, Arjun (2017).
Chronic Health Problems:
1. Bacterial conjunctivitis ICD code: H10.33
Currently controlled, patient applying ophthalmic antibiotic, avoiding the use of contact
lenses and using eye protection while riding his motorbike or avoiding this transportation.
2. Nicotine dependence, F17.210
Currently controlled, the patient smoke only 3 -4 cigarettes per day
3. Anxiety unspecified. ICD F41.9
Currently controlled, the patient feels better by starting an antibiotic.
IV. Plan
1. Diagnosis: Bacterial conjunctivitis ICD code: H10.33
Prescribed:
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Besifloxacin 0.6% Ophthalmic suspension TID x 7 days (total dispensed 1
bottle)
Patient needs an ophthalmological referral
Education:
 DO NOT stop your medication unless instructed to do so by your care provider.
 Wash hands often with soap and water for at least 20 seconds or use hand sanitizer if
soap and water are not available.
 Avoid touching your eyes with unwashed hand.
 Avoid sharing towels or bedding lining.
 Discontinue contact lens use and to discard their used contact lenses, open contact lens
solutions, used contact lens cases.
 Wear eye protection during wind exposure while riding a motorbike
 Monitor temperature daily.
 Contact your care provider, return here, or call 911 if you experience any of the
following: severe, unusual, or persistent headache, loss of vision, confusion or change in
alertness, chest pain or tightness, weakness, dizziness, or passing out, shortness of breath
or difficulty breathing.
RTC
- Return to the clinic in 2 days if redness, discharge worsens, and no improvement is noted.
- Schedule an ophthalmological evaluation after finishing the treatment.
- RTC sooner if needed or If improvement return in 1 week.
2. Nicotine dependence, F17.210
Currently controlled, the patient smoke only 3 -4 cigarettes per day
Education:
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Teach about health effects on smoking.
Patients interested in Web-based smoking cessation programs may find the
following links helpful:“ Freedom from Smoking,” available from the American
Lung Association, or The Tobacco Control Research Branch of the National
Cancer Institute (Bhanot, S., & Sharma, Arjun (2017).
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Assess: it should be determined whether the patient is ready to consider
attempting to quit and, if ready, how confident he is about success.
Assist: for those not yet ready to attempt quitting, communication lines should be
kept open for motivational messages, to let them know help is available when
they are ready (Bhanot, S., & Sharma, Arjun (2017).
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RTC:
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Follow up in 6 months and assess if the patient is determined if the patient is
ready to consider attempting to quit, or considered other alternatives to replace
tobacco consumption.
3. Anxiety, unspecified. ICD F41.9: Controlled
Treatment & Education:
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Avoid alcohol, reduced caffeine intake.
Attempt to exercise more frequently to help with energy levels and mood.
Eat a balanced diet and increase water intake.
Cognitive Behavioral Therapy will focus on modifying negative thoughts,
behaviors and emotional responses associated with distress
Relaxation techniques: Meditation improves mental health and helps with
relaxation.
Continued antibiotic as prescribed.
RTC:
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Follow up in 2 weeks for a re-check of energy levels, mood, and eye infection
symptoms. If the patient continues feeling anxious will follow up sooner to
discuss a further plan of care.
References
Dunphy, L. M. H., & Winland-Brown, J. E. (2001). Primary care: The art and science of advanced
practice nursing. Philadelphia: F.A. Davis.
Bhanot, S., & Sharma, Arjun (2017). The clinical information you need, at your fingertips. Epocrates
Web. Retrieved January 29, 2022, from https://online.epocrates.com/
ICD10 codes data. (2021). 2021 ICD-10-CM Diagnosis.
https://www.icd10data.com/ICD10CM/Codes