SOAP NOTE
Case Study: With this patient in mind, address the following in a SOAP Note:( I HAVE INCLUDED A SAMPLE SOAP NOTE FOR REFERNECE ONLY )
A 3 y/o African American female who present with her mother with a complaint of coughing for a week. Mother reports that she has been coughing every night. She has also had a mild fever of 100.5 at home. Her mother has been using a decongestant/antihistamine syrup and albuterol syrup at home from her previous prescription. Initially the cough improved but it worsened over the last 3 days. She is noted to have morning sneezing and nasal congestion and she goes to pre-school where some of her classmates were noted to be sick. She has no know allergies and up to date with immunization. Previous medical condition is asthma that has been controlled by albuterol inhaler and Nebulizer as needed
With this patient in mind, address the following in a SOAP Note:
•Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent, as well as possible reasons for these discrepancies.
•Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues.
•Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
•Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
•Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?
Reference
Readings
•Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., & Blosser, C. G. (2013). Pediatric primary care (5th ed.). Philadelphia, PA: Elsevier.
◦Chapter 31, “Respiratory Disorders” (pp. 708–738)
•Chapter 40, “Genetic Disorders” (pp. 1032–1054)
•Bradley, J. S., Byington, C. L., Shah, S. S., Alverson, B., Carter, E. R., Harrison, C., Swanson, J. T. (2011). The management of community-acquired pneumonia in infants and children older than 3 months of age: Clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clinical Infectious Diseases, 53(7), e25–e76. Retrieved from the Walden Library databases.
•National Heart, Lung, and Blood Institute. (2007). Expert panel report 3 (EPR3): Guidelines for the diagnosis and management of asthma. Retrieved from http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm
•Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis by Ralston, S.L., Lieberthal ,A.S., Meissner, H.C., Alverson, B.K., Baley, J.E., Gadomski ,A.M., Johnson, D.W., Light, M.J.,
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