NR 602 WK 5SOAP NOTE FORMAT - JO

NR 602 WK 5SOAP NOTE FORMAT - JO NR 602 WK 5 SOAP Note Format - Jo Patient Information: J.F., 6y/o Caucasian girl S. CC (chief complaint) – “Vomiting, diarrhea and fever” HPI: 6 old girl p/w vomiting x2 days/diarrhea x1 day/fever 100-101degrees/severe lower abd pain x1 day. Last meal was at a pizza buffet 36hrs ago, otherwise no solid foods since then, consumed sprite, apple juice and popsicles instead. Administered Pepto-Bismol (OTC) & Tylenol x2-3/day for fever. There are no other associated symptoms. Endorses that pt urinated this morning. Of note, pt’s brother is having similar symptoms. Otherwise no symptoms, aggravating or relieving factors identified. PMH: Jo is continuing on Ritalin, 5mg daily since you began her on this several months ago and is doing well. She has not had medication in the last two days. They both have been well since their last visit. Current Meds: Ritalin 5mg PO daily (missed 2 doses 2/2 vomiting). Used to treat ADHD. Monitor for stomach pain, nausea, vomiting, loss of appetite, vision problems, dizziness, mild headache, sweating, mild skin rash, numbness, tingling, or cold feeling in her hands or feet, nervous feeling, sleep problems (insomnia) or weight loss. Chewable MVT w/ Iron. Multivitamins are used in the prevention/treatment of vitamin deficiency and are usually sold OTC as dietary supplements. Children's chewable vitamins with iron are less likely than adult preparations to cause serious toxicity, caution should be taken when giving a child MVT with Iron because acute iron poisoning continues to be a common and potentially lethal ingestion, especially in the pediatric population. Allergies: NKDA PMHx: Full-term gestation, born cesarean section, wt 7lb 4 oz (mother smoked 1 PPD throughout pregnancy) ADHD – diagnosed 2015 No hospitalizations Immunizations: Current on all immunizations from last visit ROS: GENERAL: Pt’s mother endorses fevers. Has there been any contact with sick people? At school/daycare? How high were the fevers? When were the temperatures measured and how were they measured? Any recent weight loss? HEENT: Any recent colds/flu infections? URIs? Ear infections? Sinus infections? Sore throat? Mouth ulcerations? CARDIOPULMONARY: Any chest palpitations, SOB, chest pain? Does he have any cyanosis, activity intolerance, shortness of breath, syncope, swelling of his extremities or bluish discoloration of his extremities (cyanosis)? Any cough or sore throat? GI: Pt’s mother endorses vomiting, diarrhea and lower abd pain. Is there any odor (foul/odorless) with the diarrhea? What is its consistency (soft/watery/mixed)? What color is his BM (brown/cream/green/red)? Is there any blood with the diarrhea? How many episodes of diarrhea and vomiting have occurred? What is the smell and quantity of his vomit? What did the vomit look like (watery/thick/mixed)? What color is it (green/coffee-ground/bright red)? Any triggers? What time of the day does it happen? What is the duration? How often doe it happen? Any associated abd pain or cramping? Any abnormal masses or swelling in abdomen? Describe abd pain (sharp/throbbing/constant/reproducible)? Any aggravating or relieving factors? GU: Any signs of a urinary tract infection? Concentrated urine? Foul-smelling urine? Any difficulty with urination? Color of his urine? NEURO: Any associated headaches? Vertigo? Or stiff neck? O. GROWTH: Current - Ht: 110 cm (25th percentile), Wt: 20 kg (50th percentile), BMI is 17.5 (88th percentile). Previous visit - Ht: 107 cm (25th percentile of growth chart), Wt: 19 kg (50th percentile of growth chart), BMI of 16.6 (81st percentile). Vital Signs: B/P: 88/60, T: 101.2 tympanic, HR: 108 BMP/reg., Resp: 20, reg, non-labored, SpO2: 99%, Pain assessment missing GENERAL: lying on the exam table in fetal position; unable to lay supine 2/2 pain. HEENT: head normocephalic atraumiatic, hair thick and distributed throughout entire scalp; conjunctiva clear, non-icteric, PERRLA, EOM’s intact; tympanic membranes intact, unremarkable; nares patent, unremarkable bil; pharynx unremarkable tonsils 2/4 bil; neck supple w/o lymphadenopathy.