Soap note 6 chalazion right upper eyelid

An example of a SOAP note for a Patient with a Chazalion Right Upper Eyelid

Subjective: The patient presents today with a chief complaint of a tender lump on the right upper eyelid. Patient reports noticing the lump approximately one week ago. Patient describes mild discomfort and occasional itching. Patient denies any visual disturbances or discharge from the eye. No recent history of trauma to the eye or previous occurrence of chalazion.

Objective:

• Inspection: Right upper eyelid shows a localized, erythematous, and swollen area measuring approximately 8mm in diameter. The lump is non-mobile, firm, and tender to touch. No signs of active discharge or crusting.
• Visual acuity: Normal visual acuity in both eyes.
• Extraocular movements: Full range of motion without restriction.
• Conjunctiva and cornea: No apparent abnormalities or signs of infection.
• Pupils: Equal in size and reactive to light.

Subjective
5 Chief complaint stated in patient’s own words.
10 HPI, PMH, PSH, Family History, Social Habits,
10 Contains all systems relevant information to make assessment with normal and abnormal findings.
20 Objective present and contains all pertinent objective information available (drug allergies, physical findings, drug list, etc)
20 Assessment presents justification for Main or Primary diagnosis
15 Assessment rules out other potential disorders
5 Plan contains discussion of therapy options with pros and cons of each. Also
10 Plan stated as directives (start, stop, non-pharmacologic and pharmacologic treatment etc)
5 Plan include monitoring and follow up

NOTE:   please explain 3  differential dignosis  !!