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Soap Note For 34 Year Old Patient; D.K. is a 34-year-old Caucasian $25.49   Add to cart

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Soap Note For 34 Year Old Patient; D.K. is a 34-year-old Caucasian

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  • Soap Note For 34 Year Old Patient; D.K. Is A 34-ye

Patient Information: Initials: D.K. Age: 34 Sex: Male Race: Caucasian-American S. CC (chief complaint): "I have been experiencing redness and itchiness in both eyes". HPI: D.K. is a 34-year-old Caucasian-American male who visits the clinic for a medical examination after experiencing redn...

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  • September 19, 2024
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  • Soap Note For 34 Year Old Patient; D.K. is a 34-ye
  • Soap Note For 34 Year Old Patient; D.K. is a 34-ye
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Student’s Name:


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Date:




1

, Patient Information:

Initials: D.K.

Age: 34

Sex: Male

Race: Caucasian-American

S.

CC (chief complaint): "I have been experiencing redness and itchiness in both eyes".

HPI: D.K. is a 34-year-old Caucasian-American male who visits the clinic for a medical

examination after experiencing redness and itchiness in both eyes. The following aspects

illustrate the patient's medical status.

Location: Head

Onset: 3 days ago

Character: Pounding, pressure around the eyes and temples

Associated signs and symptoms: Nausea, vomiting, photophobia, phonophobia

Timing: After being on the computer all day at work

Exacerbating/relieving factors: Light bothers eyes; Aleve makes it tolerable but not completely

better

Severity: 7/10 pain scale

Current Medications: The patient is taking acetaminophen (Tylenol) 1300 mg) P.O. q8hr

PRN to relieve pain. The patient accessed acetaminophen (Tylenol) over the counter.

Allergies: He is allergic to dust and pollen.

PMHx: The patient received his last tetanus on 28th December 2023. He denies past major

illnesses or surgeries.



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