Soap note with 3 diagnosis and icd code and treatment plan


A 55-year-old male presents to the clinic with a chief complaint of painful, red, left eye. He states that “both eyelids are sticking together”. He complains of nasal congestion for 3 days and is taking triprolidine and pseudoephedrine. He also states that he began self-treating with sulfacetamide eye drops that he used with a previous eye infection 2 days ago. His past medical history revealed hypertension for 20 years and an eye infection 2 years ago. He states his hypertension has been well controlled until this visit. His wife died 6 months ago and he lives alone. He denies any use of tobacco but does drink alcohol occasionally. He has an allergy to Penicillin (causes rash).
Current Medications-
Triprolidine and pseudoephedrine, 2 tables PO QID X 2 days
Hydrochlorothiazide, 25 mg PO QD
Sulfacetamide eye drops, 2 drops both eyes Q6h X 2 days
Potassium chloride tablets, 10 mEq 2 tablets PO BID (states he stopped taking it several months ago)

His physical exam revealed a well-groomed male, slightly male malnourished and dehydrated; left eye is red with purulent discharge accumulated on the lashes. His vital signs are BP 155/96 and HR 65 supine, BP 130/80 and HR 100 standing, RR 23, T 98.9 F, Wt. 125.6 lbs, Ht 6 ft 2 inches. He is in sinus tachycardia. EENT exam revealed left eye brilliant red in appearance, more intense at limbus, mucopurulent discharge; right eye marginally red; both eyelids swollen; no evidence of trauma, but a well circumscribed gray lesion can be seen with fluorescein stain. Pupils react mildly to light, slightly dilated.
Labs were drawn as well as a conjunctival swab. Results are below.
Na 144, K 3.0, CL 85, HCO3 30, Bun 14, Cr 1.7, Hct 0.44, Hgb 23, Lkcs 11.4 X 109, Plts 350 X 109, Glu 101, LFT: Normal, CXR: Normal
Conjunctival swab: Gram’s stain: gram-positive lancet-shaped cocci in pairs; culture and sensitivities pending.