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Christine Dominguez

SOAP Note # 2

ID
10/10/2015, J.T. 27 year old Caucasian male; single with a steady girlfriend, religion, advanced
directives, insurance, unknown. Works as a heavy equipment operator.
CC
Awoke with bloody right eye like I blew something out.
HPI
Patient awoke this morning to find his right eye bloody after a night of heavy drinking and
subsequent multiple episodes of emesis during the night. He states his eye was normal
yesterday. He has experienced no pain, itch, or noticeable vision changes, but had some crusting
of the affected eye. He self-treated with eye drops, with no decrease in redness. There are no
noted aggravating or relieving factors. There are no temporal factors. His concern is afraid that
this may be a serious problem, and his mother is very concerned that he get this checked out with
a doctor.
PMH
Patient states his overall health has been excellent his entire life. No information given regarding
hospitalizations, immunizations, emotional status or psychiatric history. Patient denies any
previous surgeries. He does not use over the counter or prescription drug use, other than the eye
drops he tried to clear up his eye; no known allergies.
PERSONAL HISTORY
Patient lives next door to his mother, works as a heavy equipment operator. He is not married,
but does have a steady girlfriend. No information given about economic resources or abuse.
Patient is a heavy equipment operator, no information given about his safety or environment on
the job.
HEALTH HABITS
Patient does not smoke, unknown use of illicit drugs or exposure to toxins. He states his health is
excellent, drinks 5-6 beers a night on the weekends. No information given about diet, exercise,
or lifestyle.
HEALTH MAINTENANCE
No information given about his last physical exam, previous diagnostic testing, or testicular
exam.
FAMILY HISTORY
Father has diabetes and obesity, mother has hypertension.
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Christine Dominguez

SOAP Note # 2

REVIEW OF SYSTEMS
GENERAL
Patient states he has no cold symptoms, feels fine.
DIET
No information given about appetite, 24 hour diet recall.
SKIN, HAIR, NAILS
No information given
HEAD AND NECK
Patient is experiencing no headaches or dizziness. No information given about head injuries or
loss of consciousness.
EYES
Patient does not wear glasses or contacts. No information given about previous eye diseases or
problems.
EARS
No information given.
NOSE
No information given.
THROAT AND MOUTH
No information given.
GASTROINTESTINAL
Patient states his stomach feels fine now. No further information given.
LYMPH
No information given.
ENDOCRINE
No information given
MALE
No information given but is sexually active.
CHEST AND LUNGS
No information given.
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Christine Dominguez

SOAP Note # 2

CARDIOVASCULAR
No information given.
HEMATOLOGY
No information given.
GENITOURINARY
No information given.
MUSCULOSKELETAL
Patient fractured his arm at age 10.
NEUROLOGIC
No information given.
MENTAL STATUS
No information given.
Physical Examination
VS
BP: 130/84, P: 86, R: 14, height and weight not assessed
GENERAL APPEARANCE
27 year old male, dressed in neat clothes, sitting comfortably in his chair.
MENTAL STATUS
Patient is awake and alert, able to clearly articulate his symptoms, concerns, and past medical
history,
SKIN
Not assessed
HEAD
Not assessed
NECK
Not assessed
EYES
3

Christine Dominguez

SOAP Note # 2

Pupils are equal and reactive to light; dried, flaking discharge around right eye, left eye clear
with no noted exudate. Conjunctiva translucent, without erythema noted, bilaterally. Left eye
sclera white, right eye sclera with hyperemia, located from the 2:00 position, covering clockwise
to the 10:00 position, CN III, IV, VI intact by performing the six cardinal fields test. Light reflex,
and accommodation intact. Patient demonstrates 20/20 vision using the Snellen eye chart (CN
II). Fundoscopic exam demonstrates red reflex present, optic disc, without lesions bilaterally. No
nystagmus noted.
EARS
Ears without lesions or discharge. Otoscope reveals translucent tympanic membrane, without
bulging or signs of perforation. Rinne, Weber and whisper test reveal no hearing loss.
NOSE
External nose without noted deviation or deformity. No displacement of bone or cartilage or
tenderness noted with palpation. Turbinates deep pink in color, without discharge, lesions or
swelling noted.
MOUTH AND THROAT
Lips, gums, and tongue pink in color without lesions or swelling. Tonsils and palates without
swelling, redness or exudate. Uvula midline, positive gag reflex (CN IX, X).
CHEST/LUNGS
No presence of deformity to sternum, chest wall or spine. Chest with symmetric expansion,
respirations regular and non-labored. No use of accessory muscles. Tactile fremitus present, chest
resonant uniformly to percussion. Lungs clear in all fields to auscultation.
HEART
PMI noted at the left 5th intercostal space, palpable within less than 1 cm. No lifts or thrills upon
palpation. Rhythm regular, with audible S1, S2. No S3 or S4 auscultated. No splitting, gallops,
rubs or murmurs present upon auscultation.
BLOOD VESSELS
Not assessed
ABDOMEN
Not assessed
MALE GENITALIA
Not assessed

Christine Dominguez

SOAP Note # 2

RECTUM/PROSTATE
Not assessed
MUSCULOSKELETAL
Not assessed
NEUROLOGIC
Not assessed
CRANIAL NERVES
I: Not assessed.
V: Not assessed
VII: Not assessed
Diagnosis:
Subconjunctival hemorrhage secondary to profuse emesis
DIFFERENTIALS
Conjunctivitis
Episcleritis
Chemical eye irritation
PLAN
Educated patient that this will take 2-3 weeks to clear, no treatment indicated. Return to the
office if worsens, vision is altered, or he develops ocular pain, headaches, or discharge.
Discussed the avoidance of binge drinking for overall health promotion.

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