Module 6 SOAP 3
Demographics Patient: M.N.
13 years of age
Female
Hispanic
White
Chief
Complaint
(Reason for
seeking health
care)
“For the past 2 mornings, I have woken up with crusty discharge in my eyes. The
crust will slowly produce throughout the day, and my eyes are itchy, so I have to
clean them regularly.”
History of
Present Illness
(HPI)
Patient M.N is a white, Hispanic, 13-year-old who is presenting to the clinic
complaining of waking up for the past two mornings with crusty discharge in her
eyes. The patient explains that the discharge has a yellow tint. Throughout the day
she can feel her eyes starting to produce more discharge, therefore, she has been
cleaning her eye around three times a day. The patient states that when she cleans
her eyes and removes all the crust is provides comfort. The patient says her eyes are
not in pain, but they are itchy. Patient has not had a fever and or a history of any eye
infection. The patient does not wear glasses or contacts.
Allergies No allergies are diagnosed
Review of
Systems (ROS)
General: Unexpected tiredness or weight loss is denied. Denies chills, night sweats,
and fever.
HEENT: Admits to yellow crust in eyes. Admits to itchy eyes. Denies vision
changes and eye trauma. Denies pain or drainage from ear. Denies drainage and
congestion from nose. Denies throat pain or swelling.
Neck: Denies recent neck injury, swelling, pain, tenderness, and obvious masses.
Lungs: Denies difficult breathing, wheezing, and cough.
Cardio: Denies the feeling of palpitations and chest pain. Denies swelling of
extremities.
Breast: Denies palpable lumps. Denies pain and tenderness. Denies discharge from
the nipple.
GI: Denies vomiting and feeling nauseous. Denies change in bowel habits. Denies
stomach pain or cramping.
M/F genital: Denies pain and discharge.
GU: Denies changes to voiding habits. Denies pain and or burning.
Neuro: Denies having headaches, feeling dizzy, and faint. Denies changes in
coordination.
Musculo: Denies muscle and or joint pain, swelling, and stiffness.
Activity: Denies having difficulty completing everyday activities. Denies having
difficulty with physical exercise.
Psychosocial: Denies symptoms of depression. Denies feeling anxious.
Derm: Denies skin changes. Denies rashes, dryness, and or itching.
Nutrition: Denies appetite changes. Denies any food intolerances. Admits that
parents provide healthy and well-rounded meals.
Sleep/Rest: Denies difficulty sleeping and ore difficulty staying awake.
LMP: 06/01/25
STI Hx: None
Vital Signs Blood Pressure: 105/70 (left arm, sitting) Heart Rate: 86 bpm.
