SOAP Note Form #2 Clinical Practice 1
S/ Identifying Information: (initials, age/DOB, gender, reliability) Family Hx:
W. W., 25, 02/02/1994, Female, Reliable historian
Mother with HTN,
DM. Father deceased
in his 60’s. Maternal
grandmother
deceased at 96 with
pmhx of cataract.
Paternal grandparents
deceased with no
known health hx
Maternal deceased
with no known health
hx
Personal/Social Hx:
Chief Complaint/RFE: Lives with mother
“My eyes are itching and scratchy” and 3 sisters. Works
full time as a project
manager. No history
of tobacco, ETOH, or
illicit drug use
Hx Present Illness: (7 Variables but do not list as such)
The patient is a 25-year-old female complaining of itching and scratchy eyes. Itching started 10 days ago with left eye, now affects both
eyes. Milk colored purulent discharge accompanies symptom. Patient reports no erythema or foreign body sensation in eyes but states vision
as being “a little fuzzy” with purulent discharge. Itching is aggravated by scratching both eyes and relieved by scratching eyes and by sleep.
She reports use of contact lens when she goes on outings sometimes. Reports no pain but rates severity of itch as 2 on pain scale of 0 to 10.
She has not taken any medicine for itch. Denies photophobia, headache, fever, chills and malaise.
CURRENT HEALTH
, Medications: ADDERALL XR 10 mg capsules: I cap PO Q6H
Action: Sympathomimetic amine that promotes release of dopamine and norepinephrine from their storage sites in the presynaptic nerve ter-
minals; may also block reuptake of catecholamines by competitive inhibition
Typical Dose: Tablet: 5 mg PO QDay initially; may increase by 5-10 mg/day QWeek; administer daily dose in 2-3 doses; not to exceed 40
mg/day
Extended-release capsule
Adderall XR
o 20 mg PO qAM initially or switching from another medication
o May increase by increments of 5-10 mg/week; not to exceed 60 mg/day
Patent Education:
Take this medication by mouth with or without food. Take first dose when you wake up in the morning. Taking this medication late
in the day may cause trouble sleeping
Use this medication regularly to get the most benefit from it. To help you remember, take it at the same time(s) each day.
This medication may cause withdrawal reactions, especially if it has been used regularly for a long time or in high doses. In such
cases, withdrawal symptoms (including severe tiredness, sleep problems, mental/mood changes such as depression) may occur if
you suddenly stop using this medication. To prevent withdrawal reactions, your HCP may reduce your dose gradually. Please, report
any withdrawal reactions right away.
Do not increase your dose, take it more often, or use it for a longer time than prescribed. Properly stop the medication when so di-
rected. When this medication is used for a long time, it may not work as well. Talk with your HCP if this medication stops working
well, or if your condition does not improve or if it worsens.
SIDE EFFECTS: Loss of appetite, weight loss, dry mouth, stomach upset/pain, nausea/vomiting, dizziness, headache, diarrhea,
fever, nervousness, and trouble sleeping may occur. If any of these effects persist or worsen, tell your HCP promptly. Many people
using this medication do not have serious side effects.
This medication may raise your blood pressure. Check your blood pressure regularly and tell your doctor if the results are high.
A very serious allergic reaction to this drug is rare. However, get medical help right away if you notice any symptoms of a serious
allergic reaction, including: rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing.
Allergies: No allergies to medicine, environment or food
Last PE & Screenings: Eye exam 01/2019, wears glasses since 04/2017. Pap smear in January 2019 (normal)
Immunization Status: Flu shot done in October 2018. Tetanus booster 2018. No HPV vaccine. Reports childhood immunizations UTD
LMP & Birth Control (if applicable) 04/07/2019, no birth control
PMH
Illnesses & Trauma: Attention Deficit Hyperactivity Disorder (ADHD), No significant hx of trauma.
Hospitalizations/Surgeries: None
OB Hx/Sexual Hx: G0T0P0A0L0, not sexually active
Emotional/Psy Hx: None
REVIEW OF SYSTEMS
General: Denies fever, chills, fatigue, night sweats or recent weight changes.
S/ Identifying Information: (initials, age/DOB, gender, reliability) Family Hx:
W. W., 25, 02/02/1994, Female, Reliable historian
Mother with HTN,
DM. Father deceased
in his 60’s. Maternal
grandmother
deceased at 96 with
pmhx of cataract.
Paternal grandparents
deceased with no
known health hx
Maternal deceased
with no known health
hx
Personal/Social Hx:
Chief Complaint/RFE: Lives with mother
“My eyes are itching and scratchy” and 3 sisters. Works
full time as a project
manager. No history
of tobacco, ETOH, or
illicit drug use
Hx Present Illness: (7 Variables but do not list as such)
The patient is a 25-year-old female complaining of itching and scratchy eyes. Itching started 10 days ago with left eye, now affects both
eyes. Milk colored purulent discharge accompanies symptom. Patient reports no erythema or foreign body sensation in eyes but states vision
as being “a little fuzzy” with purulent discharge. Itching is aggravated by scratching both eyes and relieved by scratching eyes and by sleep.
She reports use of contact lens when she goes on outings sometimes. Reports no pain but rates severity of itch as 2 on pain scale of 0 to 10.
She has not taken any medicine for itch. Denies photophobia, headache, fever, chills and malaise.
CURRENT HEALTH
, Medications: ADDERALL XR 10 mg capsules: I cap PO Q6H
Action: Sympathomimetic amine that promotes release of dopamine and norepinephrine from their storage sites in the presynaptic nerve ter-
minals; may also block reuptake of catecholamines by competitive inhibition
Typical Dose: Tablet: 5 mg PO QDay initially; may increase by 5-10 mg/day QWeek; administer daily dose in 2-3 doses; not to exceed 40
mg/day
Extended-release capsule
Adderall XR
o 20 mg PO qAM initially or switching from another medication
o May increase by increments of 5-10 mg/week; not to exceed 60 mg/day
Patent Education:
Take this medication by mouth with or without food. Take first dose when you wake up in the morning. Taking this medication late
in the day may cause trouble sleeping
Use this medication regularly to get the most benefit from it. To help you remember, take it at the same time(s) each day.
This medication may cause withdrawal reactions, especially if it has been used regularly for a long time or in high doses. In such
cases, withdrawal symptoms (including severe tiredness, sleep problems, mental/mood changes such as depression) may occur if
you suddenly stop using this medication. To prevent withdrawal reactions, your HCP may reduce your dose gradually. Please, report
any withdrawal reactions right away.
Do not increase your dose, take it more often, or use it for a longer time than prescribed. Properly stop the medication when so di-
rected. When this medication is used for a long time, it may not work as well. Talk with your HCP if this medication stops working
well, or if your condition does not improve or if it worsens.
SIDE EFFECTS: Loss of appetite, weight loss, dry mouth, stomach upset/pain, nausea/vomiting, dizziness, headache, diarrhea,
fever, nervousness, and trouble sleeping may occur. If any of these effects persist or worsen, tell your HCP promptly. Many people
using this medication do not have serious side effects.
This medication may raise your blood pressure. Check your blood pressure regularly and tell your doctor if the results are high.
A very serious allergic reaction to this drug is rare. However, get medical help right away if you notice any symptoms of a serious
allergic reaction, including: rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing.
Allergies: No allergies to medicine, environment or food
Last PE & Screenings: Eye exam 01/2019, wears glasses since 04/2017. Pap smear in January 2019 (normal)
Immunization Status: Flu shot done in October 2018. Tetanus booster 2018. No HPV vaccine. Reports childhood immunizations UTD
LMP & Birth Control (if applicable) 04/07/2019, no birth control
PMH
Illnesses & Trauma: Attention Deficit Hyperactivity Disorder (ADHD), No significant hx of trauma.
Hospitalizations/Surgeries: None
OB Hx/Sexual Hx: G0T0P0A0L0, not sexually active
Emotional/Psy Hx: None
REVIEW OF SYSTEMS
General: Denies fever, chills, fatigue, night sweats or recent weight changes.
