NR 509 Week 6 Pediatric SOAP Note, Summer 2020 complete solution

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c 96% Medication: Denies Food: Denies Environment: Denies History of Present Illness (HPI) Chief Complaint (CC) Cough CC is a BRIEF statement identifying why the patient is here - in the pat... ient’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 Cough started 5 days ago Location throat Duration Coughing every few minutes lasting 1-2min , for the past five days. Characteristics Productive cough rated a 5 out of 10 with clear and thin sputum, cough worsens at night. Associated symptoms of sore throat and earache,(gargly and watery associated with sore throat) Aggravating Factors Worse at night. Reports cough stays the same no matter what I do. (cough at night think CHF, GERD, Asthma…) Relieving Factors Cough medicine “helped a little” Treatment resting 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 Gummy multivitamin 2-4 gummies daily Unable to answer my question when asked. “to stay healthy” Cough medicine “ a spoonful” One time “Once this AM” Cough N/A Click or tap here to Click or tap here to enter Click or tap here Click or tap here to enter text. S [Show More]

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