NURS 6541 Week 8 SOAP Note

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Comprehensive SOAP Exemplar Patient Initials: WM Age: 9 Gender: F SUBJECTIVE DATA: Chief Complaint (CC): “Were here for her 9-year physical and flu shot.” History of Present Illness (HPI): WM ... is a 9-year-old Caucasian female here today with her mother for her annual physical and flu vaccination. Mom states that MS has been coughing, runny nose of clear drainage, and sneezing on and off for the last few months. She states that symptoms worsen when she visits her sister, who lives on a farm, but also occur in the spring and fall also. She has tried Vicks on her feet and chest, which provides minimal comfort. Mom is concerned why these symptoms come and go. Denies fevers, chills, and appetite is good. She has no issues or concerns with MS’s growth or develop Reflection: I first evaluated this patient independently, obtained a history, then performed an assessment. Then the assessment was also performed with my preceptor. After the assessment was performed, my first thought was a sinus infection, but with reservation. As I progressed along, I realized that these issues are most likely allergic rhinitis. It was helpful that mother was a good historian and was able point out when the symptoms occur, such as they worsened when WM was on a farm and in the spring and fall. That leads me to believe that the animals on the farm and pollen is the trigger. My preceptor agreed with my assessment findings and diagnosis. As my clinic progresses, I realize the importance of looking at the whole picture, such as the patient’s history, and not to just focus on the symptoms. [Show More]

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