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NR 509 WEEK 7 SOAP Note Template

NR 509 WEEK 7 SOAP Note Template NR 509 WEEK 7 SOAP Note NR 509 WEEK 7 SOAP NR 509 WEEK 7 SOAP Note Template Initials: DR Age: 8 Gender:... [Show More] Male Height Weight BP HR RR Temp SPO2 Pain Allergies 50” 90 lbs 120/76 100 28 Click or tap here to enter text. Click or tap here to enter text. Choose an item. Medication: non Food: none Environment: none History of Present Illness (HPI) Chief Complaint (CC) Patient reports wet clear cough about 4-5 days, runny nose for 3 days, right ear pain for 1 day. Sore throat (minimal pain) when swallows for 4 days 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 Coughing 4-5 days with a sore throat, runny nose 3 days, earache 1 day Location Posterior pharynx, upper respiratory cough, rhinorrhea, otitis media Duration 5 days Characteristics Cough is productive, throat painful when swallowing, clear nasal drainage, pain of right ear. No fever. Denies nasal drainage Aggravating Factors Exposure to 2nd hand smoke provokes coughing Relieving Factors Minimal relief with OTC 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 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. 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, hospitalizations, and surgeries. Depending on the CC, more info may be needed. Frequent ear infections during the first two years of life. Diagnosed with pneumonia last year, no hospitalizations, no surgeries, immunizations are current and denies seasonal allergies 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. Plays video games, occasional outdoor with friend. Second had cigar smoke occasionally from father. Firearm in the house that is secured. Parents are married, both employed. Grandparents live at parents’ house. Child states he feels safe at home. Limited physical activity 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. Father had childhood asthma, HTN, Hyperlipidemia. Mother HTN and hyperlipidemia. Indication of parents being overweight. 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 Tired, not sleeping well due to frequent episodes of coughing ☐Weakness Click or tap here to enter text. ☐Fever/Chills Click or tap here to enter text. ☐Weight Gain Click or tap here to enter text. ☐Weight Loss Click or tap here to enter text. ☒Trouble Sleeping Frequent episodes of coughing ☐Night Sweats Click or tap here to enter text. ☐Other: Click or tap here to enter text. ☐Itching Click or tap here to enter text. ☐Rashes Click or tap here to enter text. ☐Nail Changes Click or tap here to enter text. ☐Skin Color Changes Click or tap here to enter text. ☐Other: Click or tap here to enter text. ☐Diplopia Click or tap here to enter text. ☐Eye Pain Click or tap here to enter text. ☐Eye redness Click or tap here to enter text. ☐Vision changes Click or tap here to enter text. ☐Photophobia Click or tap here to enter text. ☐Eye discharge Click or tap here to enter text. ☒Earache right ear pain ☐Tinnitus Click or tap here to enter text. ☐Epistaxis Click or tap here to enter text. ☐Vertigo Click or tap here to enter text. ☐Hearing Changes Click or tap here to enter text. ☐Hoarseness Click or tap here to enter text. ☐Oral Ulcers Click or tap here to enter text. ☒Sore Throat cobblestone appearance, with pain on swallowing no exudate noted ☒Congestion nasal turbinate’s reddened with bogginess ☒Rhinorrhea clear nasal drainage ☐Other: Click or tap here to enter text. Respiratory Neuro Cardiovascular ☒Cough clear productive cough ☐Hemoptysis Click or tap here to enter text. ☐Dyspnea Click or tap here to enter text. ☐Wheezing Click or tap here to enter text. ☐Pain on Inspiration Click or tap here to enter text. ☒Sputum Production Clear, small amounts thin in nature ☐Other: Click or tap here to enter text. ☐Syncope or Lightheadedness Click or tap here to enter text. ☐Headache Click or tap here to enter text. ☐Numbness Click or tap here to enter text. ☐Tingling Click or tap here to enter text. ☐Sensation Changes Choose an item. ☐Speech Deficits Click or tap here to enter text. ☐Other: Click or tap here to enter text. ☐Chest pain Click or tap here to enter text. ☐SOB Click or tap here to enter text. ☐Exercise Intolerance Click or tap here to enter text. ☐Orthopnea Click or tap here to enter text. ☐Edema Click or tap here to enter text. ☐Murmurs Click or tap here to enter text. ☐Palpitations Click or tap here to enter text. ☐Faintness Click or tap here to enter text. ☐OC Changes Click or tap here to enter text. ☐Claudications Click or tap here to enter text. ☐PND Click or tap here to enter text. ☐Other: Click or tap here to enter text. MSK GI GU PSYCH ☐Pain Click or tap here to enter text. ☐Stiffness Click or tap here to enter text. ☐Crepitus Click or tap here to enter text. ☐Swelling Click or tap here to enter text. ☐Limited ROM Choose an item. ☐Redness Click or tap here to enter text. ☐Misalignment Click or tap here to enter text. ☐Other: Click or tap here to enter text. ☐Nausea/Vomiting Click or tap here to enter text. ☐Dysphasia Click or tap here to enter text. ☐Diarrhea Click or tap here to enter text. ☐Appetite Change Click or tap here to enter text. ☐Heartburn Click or tap here to enter text. ☐Blood in Stool Click or tap here to enter text. ☐Abdominal Pain Click or tap here to enter text. ☐Excessive Flatus Click or tap here to enter text. ☐Food Intolerance Click or tap here to enter text. ☐Rectal Bleeding Click or tap here to enter text. ☐Other: Click or tap here to enter text. ☐Urgency Click or tap here to enter text. ☐Dysuria Click or tap here to enter text. ☐Burning Click or tap here to enter text. ☐Hematuria Click or tap here to enter text. ☐Polyuria Click or tap here to enter text. ☐Nocturia Click or tap here to enter text. ☐Incontinence Click or tap here to enter text. ☐Other: Click or tap here to enter text. ☐Stress Click or tap here to enter text. ☐Anxiety Click or tap here to enter text. ☐Depression Click or tap here to enter text. ☐Suicidal/Homicidal Ideation Click or tap here to enter text. ☐Memory Deficits Click or tap here to enter text. ☐Mood Changes Click or tap here to enter text. ☐Trouble Concentrating Click or tap here to enter text. ☐Other: Click or tap here to enter text. Body System Positive Findings Negative Findings General Choose an item. Overweight with BSI of 25. Alert, oriented, in no distress. Appropriate for age. Nontoxic appearance, well hydrated, and no acute distress. Appropriate interaction with healthcare provider Skin Choose an item. Click or tap here to enter text. No obvious discoloration or lesions noted HEENT Choose an item. Right ear otitis media, erythemic in nature. Posterior oral pharynx cobblestone with erythema. Erythemic tonsils with no exudates noted. Lymphadenopathy of left anterior cervical nodes. Nasal turbinate’s clear drainage with bogginess bilaterally Left ear no effusion, perforations tympanic membrane pearly grey in nature. Respiratory Choose an item. Click or tap here to enter text. Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds, equal rise and depth Neuro Choose an item. Click or tap here to enter text. Conscious, alert, orientated to time place date. Cardiovascular Choose an item. Click or tap here to enter text. Heart: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs. Musculoskeletal Choose an item. Click or tap here to enter text. No noted abnormalities Gastrointestinal Choose an item. Click or tap here to enter text. No noted abnormalities Problem List 1. Otitis media bacterial 6 Pneumonia 11 Overweight 2 pharyngitis bacterial 7 Nasal congestion / rhinorrhea 12 Click or tap here to enter text. 3 Otitis media viral 8 flu 13 Click or tap here to enter text. 4 Pharyngitis viral 9 EBV 14 Click or tap here to enter text. 5 Bronchitis 10 mononucleosis 15 Click or tap here to enter text. Acute upper Respiratory infection J06.9 Productive cough, rhinorrhea Otitis media right ear H66.91 / Z77.22 Right ear erythema Acute pharyngitis J02.9 Erythema of mucous membranes of oropharynx Cough R05 Bout of coughing Diagnostics: List tests you will order this visit Test Rationale/Citation Rapid strep Test Determine if viral or bacterial pharyngitis (Centers for Disease Control and Prevention.2019). Throat culture swab Confirmation of rapid strep / sensitivity to antibiotics (Centers for Disease Control and Prevention.2019). Medications: List medications/treatments including OTC drugs you will order and “continue previous meds” if pertinent. Drug Dosage Length of Treatment Rationale/Citation Pseudoephedrine suspension 10 ml 4-6 hrs prn No more than two dose a day, continue for 7 days if needed Relieve nasal congestion Diphenhydramine suspension 10 ml 30 minutes before bedtime Continue for 7 days if needed Reduction of rhinorrhea Dextromethorphan ER suspension 5 ml before bed 7 days if needed Cough suppressant Amoxicillin 875 mg two times daily 7 days If Rapid strep is positive or throat culture positive after 72 hrs Wait and see. Suspect viral due to 5 days since onset afebrile Motrin 400 mg every 8 hrs for pain or fever 10 days (Farrel, 2018) Warm Saltwater Gargle ½ teaspoon in 8 ounces of warm water PRN to soothe throat To be determined by need of patient (Centers for Disease Control and Prevention.2019). Referral/Consults: Emergency Department if acute shortness of breath occurs Rationale/Citation Click or tap here to enter text. Education: Discontinue all over the counter cough / cold medicine. No combinations medications, single ingredient only. Multi ingredient medication increases the risk of accidental overdose. Also, may contain medication already prescribed or not needed. Discuss the need to increase physical activity to include but not limited to 30 minutes a day of increased activity. Fever is a natural process that the body uses to kill virus and bacteria. Limit treatment based on child’s condition or if fever is over 101. Noting that the highness of fever does not indicate the degree of illness. If fever occurs, medicate with Motrin. If fever continues slow start cooling measures. Do not cover head during fever to keep patient warm. No evidence supports the adherence of not using blankets, however limit to one is encouraged. Rationale/Citation Prevention of overdose (Centers for Disease Control and Prevention.2019). Follow Up: Indicate when patient should return to clinic and provide detailed instructions indicating if the patient should return sooner than scheduled or seek attention elsewhere. Recheck in 72 hrs, if not better consider flu swab maybe considering initiated antibiotic therapy. Rationale/Citation High suspension for viral in origin if symptoms worsens must consider bacterial etiology (Centers for Disease Control and Prevention.2019). References Include at least one evidence-based peer-reviewed journal article which relates to this case. Use the correct APA 6th edition formatting. Farrel, S. E. (2018). What are the recommended maximum daily dosages of acetaminophen in adults and children? Retrieved from https://www.medscape.com/answers/820200-27207/what-are-the-recommended-maximum-daily-dosages-of-acetaminophen-in-adults-and-children Centers for Disease Control and Prevention. (2019). Pharyngitis (Strep Throat). Retrieved from https://www.cdc.gov/groupastrep/diseases-hcp/strep-throat.html [Show Less]

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