Eye exams in Tustin involve many tests to determine the best possible treatments.

SOAP, Beyond Clean! Part 2

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After attaining a good patient history, it is important for me to assess the patient’s condition objectively. This is the second part of the S.O.A.P note; subjective, objective, assessment, plan. Something that is subjective is influenced by personal feelings, tastes, and opinions. To be objective, something must be rooted out independent of these personal feelings and opinions. The patient will report the subjective details about the reason for their visit then it is my duty to further investigate. Objective signs are used to support the patient’s symptoms and ultimately, my final diagnosis. It is critical that I be able to objectively come to a conclusion without relying on the patient’s self-reported symptoms. This allows me to verify the patient’s diagnosis based on facts and clinically traceable signs.

Let’s look at the example from SOAP Part I again. The patient presented with a complaint of “my eyes are often red.” Once I ask a series of problem focused questions, I have a thorough medical history which helps me narrow down my potential diagnosis. For this example, the diagnoses are infection, allergy, and dryness. The objective signs I expect to see are different for each of these diagnoses. In the case of infection, the main difference I may expect to find is discharge. For allergy, I would expect to find swelling of various parts of the eye, papillae behind the eyelids and no pre-auricular node hardness. Finally, dryness would show decreased tear break-up time and corneal defects would be evident with staining.

As you can see, the patient can come in with subjective symptoms which are shared by multiple conditions. The objective signs however, are more unique for each condition. To make an accurate diagnosis, objective evidence is needed to clearly and accurately come to the correct diagnosis. Stay tuned for the next part of the series SOAP, Beyond Clean to learn about the assessment of the diagnosis, the “A” in SOAP.

Blog contribution by Jennifer Aslam, Optometry Intern, College of Optometry, Western University of Health Sciences.

SOAP, Beyond Clean! Part 1

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Recording a good history of a patient during an examination is the first step to a proper diagnosis. This is why S.O.A.P notes, an acronym for subjective, objective, assessment, and plan, are so important to all health care professions. First, this essential framework of a medical examination consists of noting subjective elements, such as a chief complaint.  These help paint a picture of why a patient is presenting in my chair and include medical conditions, medications in use, smoking status, family and social history. Often I can formulate a diagnosis based on this essential step.

This may not seem intuitive, but effectively utilizing subjective questions can develop a chief complaint that may be vague. For example, many patients present with a complaint of “my eyes are often red”. Red eyes commonly illicit thought of the viral infection pink eye. However, red can signify allergy, dryness, or a host of other infections. Gathering subjective history allows me to determine when and how the redness began, if it is constant or intermittent, occurring in one or both eyes, or if there is a related medical history.  I can then quickly narrow down potential diagnosis.

Another common example is a chief complaint of blurry vision either at distance, up-close or both. During my subjective course of an examination I will review social issues regarding daily use of vision such as driving, reading, and computer use. I proceed to discuss what patients do for a living, often uncovering a 12-hour day of digital device use!

Discovering such facts about a patient’s daily routine exemplifies how this first piece of my examination help me determine which tests I will need to complete to find a diagnosis and treatment.  Watch for the next part of the series SOAP, Beyond Clean! for a look at the objective examination, or the “O” of SOAP.

Blog written with Moamen Rizk, Optometry Intern, College of Optometry ,Western University of Health Sciences