SOAP Note for Glaucoma

Subjective Assessment: Glaucoma SOAP Note
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Subjective Assessment: Glaucoma SOAP Note
Subjective
The patient is a pleasant 51-year-old black woman with experience of blurry vision in her eyes. The blurry vision is more significant in the left eye than in the right for several months. The loss of vision is a problem developed recently. According to her previous ocular history, she has records of dry macular degeneration and past significant cataract surgeries in the right and left eyes. She also has past treatment for primary ocular hypertension. She is also undertaking diabetes mellitus doses. Based on PMH (past medical history), the patient has no allergies, chronic disorders, medical intolerances, and significant traumas.
Family History
Her father was diagnosed with glaucoma at age 37, and her mother is deceased. Her siblings are healthy. According to her social setting, she runs a grocery retail shop in Canada. She is married and a mother of three.
ROS (Review of Systems)
She has refutable coldness, fever, and night sweats. She also has skin bruises, rashes, and discoloration, but no skin lesions. She complains of diminished vision and painful eyes. She refutes difficulties in breathing, ulcers, and palpations.
Objective
After a thorough examination, the woman’s vision in the right eye was 20/40, and the left eye was 20/30. The patient’s intraocular pressure is approximately 08mmHg. The results of anterior segment analysis depicted a posterior space of intraocular lenses in her eyes. In both eyes, intraocular pressure was recorded at 20. After a fundus examination, the right eye retina was slated at 360 degrees but no presence of holes or tears. In the macular, she had drusen and a small patch of subretinal fluid sequential to the optic disc, excluding the fovea. The examination did not avail cystoid macular edema. There was an absence of lipid exudation or reti...