NR 509 Week 6 Pediatric SOAP Note

Document Content and Description Below

SOAP Note Template Initials: DR Age: 8 Gender: male Height Weight BP HR RR Temp SPO2 Pain Allergies 127cm 40.8kg 120/ 76 100 28 37.2C 96% Medication: none Food: none Environment: none History... of Present Illness (HPI) Chief Complaint (CC) “cough” “runny nose” “right ear pain” “tired” “sore throat” CC is a BRIEF statement identifying why the patient is here - in the patient’s own words - for instance "headache", NOT "bad headache for 3 days”. Sometimes a patient has more than one complaint. For example: If the patient presents with cough and sore throat, identify which is the CC and which may be an associated symptom Onset 5 days ago Location Throat, right ear Duration Coughing:Constant with episodes every few minutes; Ear/Throat: constant: 1 day Characteristics Cough: gurgly, watery, constant; Throat: sore, painful to swallow; Ear: constant pain Aggravating Factors Laying down at night Relieving Factors Cough medicine Treatment Cough medicine Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products. Medication (Rx, OTC, or Homeopathic) Dosage Frequency Length of Time Used Reason for Use Childrens Multivitamin Gummies One gummy Once PO daily Click or tap here to enter text. supplement Cough syrup One spoonful One dose this am cough Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses, S: Subjective Information the patient or patient representative told you This study source was downloaded by 100000831988016 from CourseHero.com on 05-01-2022 09:02:24 GMT -05:00 hospitalizations, and surgeries. Depending on the CC, more info may be needed. Pneumonia 1 year ago-unsure of medication given Recurrent ear infections at younger age Frequent colds Frequent nasal drainage No surgical history No prior hospitalizations Up to date on childhood immunizations Not up to date on flu vaccination Attends biannual primary care visits- Last physical: 2 months ago Attends yearly dental exams No history of eye exams Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent data. Include health promotion such as use seat belts all the time or working smoke detectors in the house. Lives at home with mother, father, grandmother and grandfather Household uses English primarily as language; Secondary: Spanish Father smokes cigars on occasion in the household Student in the 3rd grade Enjoys English and computers Hobbies: playing video games, writing stories Exercise: Gym class daily, going to park with friends after school and on weekends when nice out Wants to be a director when he is older with his friend Tony, who will be an actor Fears: Bad guys in movies Diet: Dislikes veggies; drinks 7-8 glasses of water a day; Breakfast: cereal, fruit, waffles, eggs, bacon Lunch: sandwich, chips, applesauce, pudding Dinner: chicken, rice, ham, stew Bowel Regimen: 1-2 bowel movements daily Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent. This study source was downloaded by 100000831988016 from CourseHero.com on 05-01-2022 09:02:24 GMT -05:00 Mother: DM, hyperlipidemia, htn, spinal stenosis, obesity Father: hyperlipidemia, smoker, childhood asthma, htn Maternal Grandmother: DM, htn Maternal Grandfather: smoker, eczema Paternal Grandmother (deceased) in mva at 52 Paternal Grandfather: Unknown Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis Check the box next to each positive symptom and provide additional details. Constitutional Skin HEENT ☒Fatigue feels tired ☐Weakness denies ☐Fever/Chills denies ☐Weight Gain Click or tap here to enter text. ☐Weight Loss Click or tap here to enter text. ☒Trouble Sleeping due to coughing ☐Night Sweats Click or tap here to enter text. ☐Other: Click or tap here to enter text. ☒Itching legs on occasion ☐Rashes denies ☐Nail Changes denies ☐Skin Color Changes Click or tap here to enter text. ☐Other: Click or tap here to enter text. ☐Diplopia denies ☐Eye Pain denies ☐Eye redness denies ☐Vision changes denies ☐Photophobia denies ☐Eye discharge denies ☒Earache R ear 3/10 pain ☐Tinnitus denies ☐Epistaxis denies ☐Vertigo denies ☐Hearing Changes denies ☐Hoarseness denies ☐Oral Ulcers denies ☒Sore Throat 2/10 pain ☐Congestion denies ☒Rhinorrhea chronic ☐Other: Click or tap here to enter text. Respiratory Neuro Cardiovascular ☒Cough constant, clear mucous ☐Hemoptysis denies ☐Dyspnea denies ☐Wheezing denies ☐Pain on Inspiration denies ☒Sputum Production ☐Syncope or Lightheadedness denies ☐Headache denies ☐Numbness denies ☐Tingling denies ☐Sensation Changes ☐Speech Deficits denies ☐Other: Click or tap here to ☐Chest pain denies ☐SOB denies ☐Exercise Intolerance denies ☐Orthopnea denies ☐Edema denies ☐Murmurs denies ☐Palpitations denies ☐Faintness denies ☐OC Changes denies ☐Claudications denies ☐PND denies ☐Other: Click or tap here to enter text. This study source was downloaded by 100000831988016 from CourseHero.com on 05-01-2022 09:02:24 GMT -05:00 ☐Other: clear mucous production enter text. MSK GI GU PSYCH ☐Pain neck ☐Stiffness denies ☐Crepitus denies ☐Swelling denies ☐Limited ROM ☐Redness denies ☐Misalignment denies ☐Other: Click or tap here to enter text. ☐Nausea/Vomiting denies ☐Dysphasia denies ☐Diarrhea denies ☐Appetite Change denies ☐Heartburn denies ☐Blood in Stool denies ☐Abdominal Pain denies ☐Excessive Flatus denies ☐Food Intolerance denies ☐Rectal Bleeding denies ☐Other: Click or tap here to enter text. ☐Urgency denies ☐Dysuria denies ☐Burning denies ☐Hematuria denies ☐Polyuria denies ☐Nocturia denies ☐Incontinence denies ☐Other: Click or tap here to enter text. ☐Stress denies ☐Anxiety denies ☐Depression denies ☐Suicidal/Homicidal Ideation denies ☐Memory Deficits denies ☐Mood Changes denies ☐Trouble Concentrating denies ☐Other: Click or tap here to enter text. GYN ☐Rash denies ☐Discharge denies ☐Itching denies ☐Irregular Menses n/a ☐Dysmenorrhea n/a ☐Foul Odor n/a ☐Amenorrhea n/a ☐LMP: n/a ☐Contraception n/a ☐Other: O: Objective Information gathered during the physical examination by inspection, palpation, auscultation, and palpation. If unable to assess a body system, write “Unable to assess”. Document pertinent positive and negative assessment findings. This study source was downloaded by 100000831988016 from CourseHero.com on 05-01-2022 09:02:24 GMT -05:00 Body System Positive Findings Negative Findings General Appears uncomfortable due to symptoms of coughing and sore throat Negative for odor, malnourishment, Disorientation Skin Negative for Cyanosis, lesions, scarring, edema, rashes HEENT Right auditory canal and tympanic membrane is erythemic Tonsils erythemic Posterior oropharynx is erythemic and has cobblestone texture Cervical Lymph nodes palpable and tender upon [Show More]

Last updated: 1 year ago

Preview 1 out of 8 pages